GENERAL COURSE APPLICATION FRANK BABINEC Fire Chief I would like to apply for the following course (check only one): ARSON ☐ Arson Investigation ☐ Fire/Arson Origin & Cause ☐ First Responder Role ☐ Latent Investigation/Forensics LIVE FIRE ☐ LFTI ☐ LFAT ☐ LFTI Refresher DIVE CLASSES ☐ Dive Rescue ☐ Diver Survival EVOC ☐ EVOC MEDICAL ☐ CPR ☐ EMR ☐ ACLS ☐ PALS ☐ BLS ☐ PHTLS DRIVER ENGINEER ☐ Driver Engineer ☐ Aerial App. Operator ☐ Hydraulics Refresher ☐ Apparatus Refresher FLUSAR ☐ Rope Ops ☐ Rope Tech ☐ Confined Space Ops ☐ Confined Space Tech ☐ Trench Ops ☐ Trench Tech ☐ Structural Collapse ☐ VMR Ops ☐ VMR Tech SURVIVAL ☐ FAST ☐ OTHER__________________________________ FIRE OFFICER/SAFETY OFFICER ☐ Fl. Incident Safety Officer ☐ Fl. Health & Safety Officer ☐ Legal Consideration ☐ Course Delivery ☐ Course Design ☐ Public Information Officer ☐ Building Construction ☐ SERP ☐ Company Officer ☐ Fire Tactics I ☐ Fire Tactics II ☐ Fire Prevention ☐ Private Fire Protection _________________________________________________________________________________________________________________________________________________________________ Last Name First MI Date of Birth _________________________________________________________________________________________________________________________________________________________________ Home Address City State Zip _________________________________________________________________________________________________________________________________________________________________ FCDICE1 or SSN Contact Phone Number Email Address _________________________________________________________________________________________________________________________________________________________________ Fire Department (if employed) Date of Course Please answer the following questions by checking the appropriate space. YES NO ___ ___ Have you attached the appropriate registration fees and tuition (Visa, MC, cashiers’ check or money orders only) ___ ___ Have you completed the Release and Waiver form? ___ ___ Have you included copies of certifications for pre-requisites? ___ ___ I agree to accept email notifications from the Coral Springs Fire Academy for future classes. _________________________________________________________________________________________________________________________________________________________________ Applicant Signature 1 Date FCDICE is required in order to receive credit with the Florida State Fire College. The Coral Springs Fire Department Training Academy must notify individuals of the circumstances that require or authorize the collection and use of social security numbers (SSN). Florida Statute 119.71 (5) specifically authorizes the academy to collect SSN’s where required by law or where the SSN is imperative in the performance of its duties. In this instance, the academy is collecting the SSN for use in the proper identification and background screening of students. Social security numbers are kept confidential and will be securely maintained. SSN’s will not be disclosed for any other reasons unless required by law or a court order. CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY 4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423 FRANK BABINEC Fire Chief RELEASE AND WAIVER I ________________________________________, as a participant in the City of Coral Springs Fire Department training given on ____________________, 20___, agree to sign this Release and Waiver. Accordingly, I agree to unconditionally release, waive, and discharge the City of Coral Springs, its Commission members, employees, agents, and servants, all hereafter referred to as "releasees," from all claims and courses of action, that I, my personal representatives, assigns, heirs, and next of kin, may have for any loss, damage, or injury to person or property, whether caused by the negligence, or otherwise of the releasees. In addition, I agree to indemnify completely, the releasees against all claims, demands, and actions arising out of my actions or involvement with the City of Coral Springs. I certify and warrant that I am in good physical condition and able to participate in the above activity. I HAVE CAREFULLY READ THE FOREGOING RELEASE AND WAIVER AND KNOW THE CONTENTS THEREOF AND HAVE SIGNED THIS RELEASE AND WAIVER AS MY OWN FREE ACT. I expressly agree that this Release and Waiver is intended to be as broad and as inclusive as permitted by the laws of the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall notwithstanding, continue in full force and effect. In Witness Whereof, I have ___________________________, 20___. executed this Release and Waiver By:________________________________ (Name) By:________________________________ (Printed Name of Signator) I asked the Signator if he/she understood what is being signed. ___________________________________ Witness CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY 4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423 on