Applicant’s Name: Last First

for office use only

FIRE ACADEMY APPLICATION PACKET Applicants must read the Information Packet located on the MVC website prior to filling out this application

Applications may be submitted in person Monday-Friday or Certified Mail

Moreno Valley College Fire AcademyBen Clark Training Center

Attn: Fire Academy Coordinator16888 Bundy Avenue

Riverside, California 92518

Applicants may apply with prerequisites in progress however: • Applicants with completed prerequisites will be given priority.• Submit a letter explaining missing pre-requisites• All prerequisites must be completed prior to the end of the FIT S3A.• Please contact the Fire Technology Office at (951) 571-6197 if you have questions. (Rev10/19)

Cadet Application Checklist Pre-Requisites

_______ Fire Protection Organization Transcript

_______ Current copy of CA State EMT Certification or NREMT Card

_______ Successful Physical Abilities Test (Biddle or CPAT) within 1 year of Academy start date

Other Required Signed Documents

_______ Basic Firefighter Academy Acceptance Policy

_______ Basic Firefighter Academy Hold Harmless Agreement

_______ Release & Waiver for use of Visual & Audio recordings

_______ BCTC Dress Code Policy

_______ Physical Training Release Form

_______ RPP and Physical Release Form signed by Health Care Provider

_______ Nomination | Sponsorship Letter (if applicable) Department: _______________________.

Date:

Time:

Received by:

Applicant #

Please contact the Fire Technology Office at (951) 571-6197 if you have questions. (Rev 10/19)

Basic Fire Academy Application Personal Information

Name: Last First MI (REQUIRED)

Address: Street City State Zip

Date of Birth: Age: Day/Month/Year must be 18 years of age

Phone: Home Cell

Email address:

Medical Insurance Provider:

Emergency Contact Name and Phone:

Educational Background

High School: Year of Graduation:

College:

Units Completed: Degree: Year of Graduation:

Fire Experience If applicable, include department, supervisor’s name & phone number, and dates of service

Military Experience If applicable, list branch, dates of service, rank, and career field:

PREREQUISITES: Initial ONLY if successfully completed:

_____ California EMT Certified or National Registry (NREMT) Card

_____ Fire Protection Organization (FIT-1) or equivalent

_____ Physical Abilities Test (Biddle or CPAT) within 1 year of the academy start date.

Please contact the Fire Technology Office at (951) 571-6197 if you have questions. (Rev10/19)

Basic Firefighter Academy Acceptance Policy Due to the overwhelming demand for the MVC Basic Firefighter Academy, acceptance into the program is based on the following:

Industry sponsorship and open enrollment

• Only complete applications will be accepted.• Sponsoring agencies have the first right of refusal for their allotted positions.• The Fire Academy Coordinator may reassign positions to other agencies as needed.• Positions not filled by agencies will convert to open enrollment.• The academy will accept a minimum of 15% open enrollment.• Applications for enrollment that exceed the class maximum will be placed into a lottery for selection.

Participating Riverside County Training Officers’ Association (RCTOA) Fire Agencies:

• Cathedral City F.D. (allotted 2 spots)• Corona F.D. (allotted 2 spots)• Hemet F.D. (allotted 2 spots)• Idyllwild F.D. (allotted 2 spots)• Morongo F.D. (allotted 2 spots)• Murrieta F.D. (allotted 2 spots)• Palm Springs F.D. (allotted 2 spots)• Pechanga F.D. (allotted 2 spots)• Riverside City F.D. (allotted 2 spots)• Riverside County / CAL Fire (allotted 4 spots)

Sponsorships & Nominations- Any financial support given to a cadet is at the agency’s discretion.

• Sponsoring department will be responsible for replacing or repairing equipment that may be damaged under normalcircumstances during the academy.

• A Sponsorship letter on Department letterhead must be attached to a sponsored applicant’s completed application.

• A Nomination letter on Department letterhead must be attached to a nominated applicant’s completed application.

*Sponsored applicants must have all fire academy requirements completed at time of application*

Signature

I have read and understand the above policy certify that I meet the minimum requirements for academy enrollment and have read the academy information packet prior to submitting this application.

Print Name (Applicant) Signature (Applicant) Date

Please contact the Fire Technology Office at (951) 571-6197 if you have questions. (Rev10/19)

Riverside Community College District on behalf of Moreno Valley College Basic Firefighter Academy Hold Harmless Agreement

I _________________________________________ wish to attend the Moreno Valley College’s Basic Fire Academy at the Ben Clark Training Center. I understand that the training consists of physical conditioning activities and hands on “skills testing”, as it relates to the fire service. The physical conditioning program consists of rigorous physical exercise for 1 hour a day minimum, 5 days a week, for approximately 12 weeks.

The skills related to firefighting activities will include heavy lifting, climbing and other arduous activities while on the ground, on ladders, in stairways, on roofs and other elevated locations. I understand that I will also have to perform in confined spaces and in areas of limited or zero visibility. I understand that I will be required to wear firefighting protective clothing including coat, pants, boots, helmet and a 35-pound self contained breathing apparatus. I understand that I will also engage in actual fire fighting, in extreme IDLH (Immediately Dangerous to Life and Health) environments.

The physical conditioning involves exercise focusing on cardiovascular endurance as well as muscular strength. The intensity of the various exercises is individualized to the ability of the academy class and is generally increased throughout the course of the program.

Each exercise session lasts approximately 60 minutes and consists of an 8-10 minute warm-up, 30-45 minute conditioning session focusing on a primary training objective, and 3-5 minute cool-down. Physical exercises may include, but are not limited to, sit-ups, leg raises, push-ups, and ¼ to 5-mile runs, wind sprints and pull-ups.

I understand the inherent dangers of fire service activities and the training involved in the Basic Fire Academy. I have shown proof of medical insurance to cover any injuries that may occur because of my participation in the Basic Fire Academy and agree not to hold Moreno Valley College or its Staff liable for any injuries that may occur during instruction.

I HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE THE RIVERSIDE COMMUNITY COLLEGE DISTRICT, ITS TRUSTEES, OFFICERS, EMPLOYEES, AGENTS OR VOLUNTEERS, AND IF APPLICABLE, OWNERS AND LESSORS OF PREMISES ON WHICH THE ACTIVITY TAKES PLACE FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED BY OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE “RELEASEES.” I FURTHER AGREE, THAT IF, DESPITE THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, OR ANYONE ON MY BEHALF, MAKES A CLAIM AGAINST ANY OF THE RELEASEES, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ARBITRATION EXPENSES, MEDICAL EXPENSES, ATTORNEY FEES, LOSS, LIABILITY, DAMAGE OR COST WHICH MAY BE INCURRED AS THE RESULT OF SUCH CLAIM.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

Print Name (Applicant) Signature (Applicant) Date

RELEASE AND WAIVER FOR USE OF VISUAL OR AUDIO RECORDINGS

This Release and Waiver is for the following Materials:

___ (1) Photo(s), graphic(s), or other static artwork as specified:

________________________________________________________________________

___ (2) Film, video, or other moving artwork as specified:

________________________________________________________________________

___ (3) Music or sound recording(s) as specified:

________________________________________________________________________

I, the undersigned, hereby grant to Riverside Community College District (RCCD) permission to use,

exploit, adapt, modify, reproduce, distribute, publicly perform or display, in any form now known or later

developed, the Material specified in this Release and Waiver as identified above (the “Materials”),

throughout the world, by incorporating them into publications, catalogues, brochures, books, magazines,

photo exhibits, motion picture films, videotapes, and/or other media (the “Works”) or commercial,

informational, educational, advertising, or promotional materials relating thereto.

I release, and hereby agree to indemnify, defend, and save harmless RCCD, its agents, employees,

licensees and assigns (collectively, “Released Entities”) from any and all claims I, or any third party, may

have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation

or any other cause of action arising out of the use, exploitation, reproduction, adaptation, distribution,

broadcast, performance or display of the Materials. I further agree to indemnify, defend, and hold

harmless the Released Entities from and against any lawsuit or cause of action against the Released

Entities based upon, arising out of, or otherwise relating to the Materials, including without limitation,

any cause of action relating to copyright infringement.

I waive any right to inspect or to approve any Works that may be created using the Materials and waive

any claim with respect to the eventual use to which the Materials may be applied.

I understand and agree that RCCD is and shall be the exclusive owner of all right, title, and interest,

including copyright, in the Works, and any commercial informational, educational, advertising, or

promotional materials containing the Materials. I understand I will not be compensated for use of the

Materials, time spent in making the Materials, or have any right to any future royalties from or related to

the use of the Materials.

I am of full legal age and have read this Release and Waiver and am fully familiar with its contents. By

their signature below, a minor’s parent(s) or legal guardian(s) indicate, on behalf of their minor child,

their full and unqualified consent to the terms of this Release and Waiver.

Name:______________________________________________________ Age (if Minor):_____

Signature (not required if Minor):___________________________________________________

Name of Parent/Guardian if Minor:_________________________________________________

Signature of Parent/Guardian if Minor:______________________________________________

Date:_____________________________

Please contact the Fire Technology Office at (951) 571-6197 if you have questions. (Rev10/19)

Ben Clark Dress Code Agreement Appropriate dress for class is required. It is the student’s responsibility to maintain a clean, neat and professional appearance. Some courses may require the wearing of uniforms or special attire. Course coordinators and/or course announcements may specify either a style or type of dress for a specific course.

Acceptable dress includes:

• Approved department or academy uniform.• Males: Casual business pants and shirt with collar.• Females: Casual business pants or business dress and shirt/blouse with collar.

Unacceptable dress includes:

• T-Shirts• Flip-Flops• Cutoffs/Shorts• Any shirt/blouse without a collar, including t-shirts, tank tops or halter tops• Clothing which is inappropriately worn, stained, soiled or wrinkled• Clothing or decoration which expresses a political opinion, or expresses an attitude or opinion contrary

to the public safety codes of ethics• Students may not wear a hat inside any facility except as specifically required by the course they are

attending.

Students who do not comply with the dress code may be asked to leave the premises.

Print Name (Applicant) Signature (Applicant) Date

Please contact the Fire Technology Office at (951) 571-6197 if you have questions. (Rev10/19)

Physical Fitness Training Certification, Waiver & Release

I , hereby certify and acknowledge that: (Please print name)

1. I have been advised that physical fitness training is part of the requirement for completion of theIntroduction to Fire Academy Physical Conditioning course (FIT-S3A).

2. I am fully informed of the nature and the extent of the tasks required by the physical fitness training.3. I have no known medical, physical, psychological or other reasons that would prevent me from

participating in the physical fitness training.

THEREFORE, in consideration for permitting the above-named and undersigned applicant to participate in physical fitness training, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, property damage or wrongful death occurring or arising as a result of any of the following: receiving instructions in the physical fitness training, any activities incidental to physical fitness training, or the actual engagement in the physical fitness training. The undersigned agrees that under no circumstances will he/she or his/ her heirs, executors, administrators or assigns prosecute, present any claim for personal injury, property damage or wrongful death against Riverside Community College District or any of its officers, agents, servants or employees for any of the said causes of action, whether the same shall arise by negligence of any of the said persons otherwise.

IT IS THE INTENTION OF THE APPLICANT AND UNDERSIGNED BY THIS INSTRUMENT, TO EXEMPT AND RELIEVE RIVERSIDE COMMUNITY COLLEGE DISTRICT AND ANY OF ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE.

The undersigned acknowledges that he/she has read the foregoing certification, waiver & release and understands fully the content thereof, and that he/she has been completely advised of the potential dangers incidental to engaging in physical fitness training, and that he/she is fully aware of the legal consequences of signing the within instrument.

Signature Date

Medical Evaluation Questionnaire | Applicant’s Printed Name______________________________________________________________________________________

Rev. 10/19

ALL QUESTIONS MUST BE ANSWERED COMPLETELY WITH A YES, NO, NONE OR NOT APPLICABLE. FOR HEALTHCARE PROVIDER REVIEW ONLY. DO NOT SUBMIT QUESTIONNAIRE WITH APPLICATION. ONLY PHYSICAL RESULTS PAGE.

Date:

Last Name: MI: Suffix: Mailing Address: State:

Zip Code:

Home Phone No:

Last 4 SSN:

First Name:

City:

Alternate Phone No: Date of Birth: Age:

To the Applicant: Can you read (check one): Yes No The medical questionnaire was developed by Cal/OSHA as part of the comprehensive medical evaluation process to determine

fitness to use respiratory protection equipment. For your protection and privacy, it is important that this confidential medical questionnaire not be shared with those not involved in the medical review process.

Part A - Section 1. The following information must be provided by every applicant required to use any type of respirator (please print). 1. Sex (check one): Male Female 2. Your height Ft. In. 3. Your weight: Lbs 4. Your job title:

5. Phone number where you can be reached between the hours of 7:00am and 4:30 pm by the health care professional who reviews thisquestionnaire (include Area code)

6. The best time during thehours of 7:00 am and4:30pm to phone you at thisnumber

Yes No

7. Check the type of respirator you will use (Check all):a. N, R, or P disposable respirator (filter-mask, non-cartridge type only).b. Half- or full-facepiece type.c. Powered-air purifying, supplied-air.d. Self-contained breathing apparatus.

8. Have you worn a respirator?If yes," what type(s):a. N, R, or P disposable respirator (filter-mask, non-cartridge type only).b. Half- or full-facepiece type.c. Powered-air purifying, supplied-air.d. Self-contained breathing apparatus.

Section 2. (Please check applicable "YES" or "NO" box.) 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No

2. Have you ever had any of the following conditions?a. Seizures (fits). Yes No b. Diabetes (sugar disease). Yes No c. Allergic reactions that interfere with your breathing. Yes No d. Claustrophobia (fear of closed-in places). Yes No e. Trouble smelling odors. Yes No

3. Have you ever had any of the following pulmonary or lung problems?a. Asbestosis. Yes No b. Asthma. Yes No c. Chronic bronchitis. Yes No d. Emphysema. Yes No e. Pneumonia. Yes No f. Tuberculosis. Yes No g. Silicosis. Yes No h. Pneumothorax (collapsed lung). Yes No I. Lung cancer. Yes No j. Broken ribs. Yes No k. Any chest injuries or chest surgeries. Yes No l. Any other lung problem that you have been told about. Yes No

Medical Evaluation Questionnaire | Applicant’s Printed Name______________________________________________________________________________________

Rev. 10/19

4. Do you currently have any of the following symptoms of pulmonary or lung illness?a. Shortness of breath. Yes No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline. Yes No c. Shortness of breath when walking with other people at an ordinary pace on level ground. Yes No d. Need to stop for a breath when walking at your own pace on level ground. Yes No e. Shortness of breath when washing or dressing yourself. Yes No f. Shortness of breath that interferes with your job. Yes No g. Coughing that produces phlegm (thick sputum). Yes No h. Coughing that awakes you early in the morning. Yes No i. Coughing that occurs mostly when you are lying down. Yes No j. Coughing up blood in the last month. Yes No k. Wheezing. Yes No l. Wheezing that interferes with your job. Yes No m. Chest pain when you breathe deeply. Yes No n. Any other symptoms that you think may be related to lung problems. Yes No

5. Have you ever had any of the following cardiovascular or heart problems?a. Heart attack. Yes No b. Stroke. Yes No c. Angina. Yes No d. Heart failure. Yes No e. Swelling in your legs or feet (not caused by walking). Yes No f. Heart arrhythmia (heart beating irregularly). Yes No g. High blood pressure. Yes No h. Any other heart problem that you've been told about. Yes No

6. Have you ever had any of the following cardiovascular or heart symptoms?a. Frequent pain or tightness in your chest. Yes No b. Pain or tightness in your chest during physical activity. Yes No c. Pain or tightness in your chest that interferes with your job. Yes No d. In the past two years, have you noticed your heart skipping or missing a beat. Yes No e. Heartburn or indigestion that is not related to eating. Yes No f. Any other symptoms that you think may be related to heart or circulation problems. Yes No

7. Do you currently take medication for any of the following problems?a. Breathing or lung problems. Yes No b. Heart trouble. Yes No c. Blood pressure. Yes No d. Seizures (fits). Yes No

8. Have you taken any prescription or over the counter medications in the last 12 months? If yes, listprescription/medication name and dosage

Yes No

9. If you have used a respirator, have you ever had any of the following problems? Check all that apply. Yes No

a. Eye irritation. Yes No b. Skin allergies or rashes. Yes No c. Anxiety. Yes No d. General weakness or fatigue. Yes No e. Any other problem that interferes with your use of a respirator. Yes No

10. Would you like to talk to the health care professional about your answers to this questionnaire? Yes No

11. Have you ever lost vision in either eye (temporarily or permanently)? Yes No

12. Do you currently have any of the following vision problems?a. Wear contact lenses. Yes No b. Wear glasses. Yes No c. Color blind. Yes No d. Any other eye or vision problem. Yes No

13. Have you ever had an injury to your ears, including a broken eardrum? Yes No

14. Do you currently have any of the following hearing problems?a. Difficulty hearing. Yes No b. Wear a hearing aid. Yes No c. Any other hearing or ear problem. Yes No

Medical Evaluation Questionnaire | Applicant’s Printed Name______________________________________________________________________________________

Rev. 10/19

15. Have you ever had a back injury? Yes No

16. Do you currently have any of the following musculoskeletal problems?a. Weakness in any of your arms, hands, legs, or feet. Yes No b. Back pain. Yes No c. Difficulty fully moving your arms and legs. Yes No d. Pain or stiffness when you lean forward or backward at the waist. Yes No e. Difficulty fully moving your head up or down. Yes No f. Difficulty fully moving your head side to side. Yes No g. Difficulty bending at your knees. Yes No h. Difficulty squatting to the ground. Yes No i. Climbing a flight of stairs or a ladder carrying more than 25 lbs. Yes No j. Any other muscle or skeletal problem that interferes with using a respirator. Yes No

17. Have you had any surgical operations? If yes, list the type of surgery and when it was performed. Yes No Type of surgery Date of surgery

18. Have you ever suffered from a heat-related illness? If yes, please describe: Yes No

19. Are you currently under a doctor’s care? Yes No

20. Have you had any motor vehicle accidents with injuries? If yes, please describe. Yes No

Part B 1. List medications you use on a regular basis while wearing protective equipment (include over-the-counter

medications):

2. Have you ever had or been advised to have an exercise treadmill test? Yes No If yes, when was the last treadmill done?Were you advised to restrict your activities based on the results? Yes No

3. List previous occupations or activities which you believe may have exposed you to airborne toxic substances(include items such as pertinent military service, pesticide application, mining activities, rock drilling, asbestosabatement, lead abatement, etc.):

Previous Occupation/Activities Exposure

4. List any present occupations or activities that you feel may expose you to airborne toxic substances (mining,smelting metals, welding, etc.):

Present Occupation/Activities Exposure

5. Are you on a HAZMAT Team? Yes No 5a. When was your last medical clearance examination for HAZMAT work?

Date:

Final Question Is there anything about your work or medical history that should be considered in determining your ability to perform your work activities while wearing protective equipment including any condition(s) not specifically referred to in the preceding questions? If yes, please advise:

Yes No

CERTIFICATION: I certify that I have provided true and complete information concerning my health.

APPLICANT SIGNATURE DATE

Medical Evaluation Questionnaire | Applicant’s Printed Name______________________________________________________________________________________

Rev. 10/19

OSHA Respiratory Medical Recommendation and Physical Results. Sign Both Areas for RPP and Physical Clearance.

Applicant Name (Last) (First) (Middle) Provider Name

Applicant Address Provider Address

Applicant’s Current Occupation Position Title

Cadet Firefighter

Contact Name and Number

BELOW IS COMPLETED BY HEALTHCARE PROVIDER AFTER REVIEW OF RPP QUESTIONNAIRE AND PHYSICAL IS COMPLETED

HEALTHCARE PROVIDER ADMINISTRATIVE USE ONLY

RPP Questionnaire Results:

Cleared to be Fit Tested by Fire Academy Based on RPP Questionnaire:

Referred to Physician for Further Evaluation:

Provider Signature: Date:

HEALTHCARE PROVIDER ADMINISTRATIVE USE ONLY

Physical Exam Results:

Full Clearance for Academy Activity:

Referred to Physician for Further Evaluation:

Provider Signature: Date: