Fall 2018 - Preparatory Physical Training - Fire Academy PPT-FA
Welcome to our registration form. The information disclosed will be used only for your safety and accountability. If you have any questions regarding the program please contact Chief Gomola - ggmola@fairfieldct.org (203) 650-7233. If you have any questions about registration, invoice, or billing please contact Denise Sherwood - dsherwood@fairfieldct.org. (203) 254-4710 at the Fairfield Regional Fire School. Note - An invoice will be sent to the listed email on this form.
Email address *
Re-Enter Email *
just to make sure you typed in the proper email the first time :)
Your answer
"There are no secrets to success. It is the result of preparation, hard work, and learning from failure."-- Colin Powell
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Gender *
Required
Preferred Phone Number *
Your answer
“Knowing Is Not Enough; We Must Apply. Wishing Is Not Enough; We Must Do.” Johann Wolfgang Von Goethe
How did you hear about our training opportunity? *
Current Occupation
Your answer
Position Preparing for:
Will you be attending the CT Fire Academy in 2019? *
If yes - what department is sending you? *
Your answer
“When you live for a strong purpose, then hard work isn’t an option. It’s a necessity.” Steve Pavlina
Tell us your "why". What do you want to accomplish and what is your motivation? *
Your answer
Medical Information and Liability Waivers
Medical Clearance *
By checking below I certify that I have been examined by a physician and have been cleared to participate in strenuous physical activity without restriction.
Required
Medical Conditions *
Please list any medical condtions past or present including but not limited to inury or illness that we need to be aware of to insure your safety and minimize preventable injury.
Your answer
Do you have any allergies? *
If "Yes" please explain below.
Required
Please explain allergies and treatment.
If you have an epi pen or medication please note below
Your answer
Do you take any medication that would interfere with physical training? *
If "Yes" please explain below.
Required
Please list medication and contraindications
Our goal is to keep you safe, all information provided will be kept confidential and shared with staff and instructors on a need to know basis.
Your answer
Orthopedic Injuries - Breaks, Sprains, Strains *
Please list any injuries (fractures, sprains/strains, etc) and prior orthopedic surgeries.
Your answer
SCBA Notice of Hazard and Medical Clearance *
I understand that the use, care, and handling of self-contained breathing apparatus (SCBA) and performing physical training while wearing SCBA contains inherent risk of injury. I further understand that the use of SCBA places significant physical and respiratory load on the wearer. I certify that I have been examined by a physician and medically cleared to use SCBA and perform physical exercise while wearing same without restriction. Checking the box below affirms my understanding of risk potential and affirmation that I have been medically cleared to perform Self Contained Breathing Apparatus training without restriction.
Required
Informed Consent and Liability Waiver *
In consideration of entry into training with Asst. Chief George Gomola, the Town of Fairfield, the Fairfield Regional Fire School, the development staff, the instructors, assistants and volunteers of the Preparatory Physical Training – Fire Academy program I intend to be legally bound and do hereby agree to be legally bound for myself and for all successors in interest I may have, by this Contract, Waiver and Release of Liability, and hereby agree to hold harmless and indemnify Asst. Chief George Gomola, as well as all officers, members, employees, assistants, volunteers, assigns, or agents of any type whatsoever acting on or in behalf of the aforementioned entities and persons, against any claims for damages or other claims for injuries or losses of any kind suffered by me or any others, directly or indirectly, arising out of any practice, instructions, or other activity related to this program as well as participation in this program or traveling to for from this program or any other activity related to this program. I understand that the activities, exercises and training methods to be taught may not be appropriate for all people and may, in some cases, cause injury or aggravate existing injuries. I certify that I am physically able to participate in this activity and will further hold Asst. Chief George Gomola, the Town of Fairfield, the Fairfield Regional Fire School, the development staff, the instructors, assistants and volunteers of the Preparatory Physical Training – Fire Academy program, as well as any all officers, members, employees, assistants, volunteers, assigns, or agents of any type whatsoever acting on or in behalf of the aforementioned entities and persons, harmless for any injury sustained in the course of this training due to any physical defect or condition that I may have, whether now known or hereinafter discovered. I further acknowledge that in consideration for this training, this release shall not expire and shall be considered effective in perpetuity. I also understand that all exercises, training methods and concepts are to be used at my own risk and that the aforementioned trainers and entities assume no responsibility for my actions. I acknowledge if I am uncomfortable with any activity, exercise or training program within the course that I may immediately state so, and that it is my right and responsibility to remove myself from the situation immediately and that I am encouraged to do so. By checking the box below, I certify that I have understood all that is expressed in this waiver and release of liability, and I certify that I am of sound judgment, legally competent to agree to this waiver. Additionally, I certify that I am eighteen years of age or older, or a legally emancipated adult.
Required
Emergency Contact Person *
First and Last Name
Your answer
Emergency Contact Phone *
Your answer
$450 Payment and Non-Refundable Deposit *
I understand my $450 payment includes a $100 non-refundable deposit. All payments MUST be received before registration is finalized. Invoices will be emailed to the address you provided above on the Monday following your application submission. Upon receipt of your payment you will get an email confirmation regarding your enrollment.
Required
T Shirt Size *
We will be ordering T-Shirts to be issued to our candidates. These will be offered in Men's/UNISEX and Women. The women's' cut tends to run small. Please identify your T-shirt size below.
Success!
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, love of what you are doing or learning to do”― Pelé
Remember to hit "Submit"
This completes your initial application process. You will be receiving an email on the Monday following your application submission that contains an invoice that can be paid online with a credit/debit card or with a check. If you have any questions or concerns please contact Chief Gomola by email - ggomola@fairfieldct.org or by phone - (203) 650-7233. Stay safe!
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