Fire/Rescue Services Registration Form

To ensure space is reserved for you or your department, please provide the following information: 

*Required Field

*Student Name:
Please provide full name including first, last and middle initial.

*Mailing Address:

*City:

*State:

*Zip:

*County of Residence:

*Dept/Agency Name:
First time registrants must provide a letter of affiliation on Agency letterhead to be fee-exempt.

*Contact E-mail:

Home Phone:

Business Phone:

Cell Phone:

*Social Security #
NEW STUDENTS: Please provide your full social security number.
RETURNING STUDENTS: Please provide at least last four (4) digits for identification purposes.

*Date of Birth:

*Sex: MaleFemale

Race:

*Type of Course: Select One... Online Nighttime Fire Academy In-House (Department) Special

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

Course Title:   Date:
Are you taking this course to receive credit toward your certification or to satisfy your minimum training hours (will you be participating in the written/practical tests)? Select One... Yes No

High school students must also complete the Joint Approval for Concurrent Enrollment form. This form must be filled out and signed by the high school principal and turned in at least a week prior to the start date of the class if the student is less than 18 years old (16 or 17).