PROGRAM DETAILS:

LIVE FIRE TRAINING INSTRUCTOR & INSTRUCTOR IN CHARGE

APPLICATION REQUIREMENTS:

NOV 1-5, 2021

Program fee: $350. This course will take place at the Town of Yarmouth Fire Rescue Facility at 178 North Road. Participants will adhere to all COVID-19 safety guidelines in place during the course dates.

All application materials must be submitted to Anne Heinig (aheinig@smccme.edu, or MFSI ATTN: Anne Heinig, 19 Sewall St, Brunswick ME 04011) by October 22, 2021. Please do not send payment with your application: the attached COVID-19 Billing Procedure form must be completed, and an invoice will be sent after the start of the course.

THIS PROGRAM IS PROVIDED IN COLLABORATION WITH ALABAMA FIRE COLLEGE

& PERSONNEL STANDARDS COMMISSION

MFSI has partnered with Alabama Fire College to bring this valuable training program to Maine.

Representatives of Alabama Fire College will be traveling to Yarmouth to provide NFPA 1041 2019

Edition Live Fire Instructor/Instructor in Charge. This is a 40 hour Pro-Board Certified Program.

Space will be limited to 24 candidates.Applications must include: completed registration packet; recommendation letter from your Fire Chief; proof of FF I & II (Pro Board) and FI I & II certifications; 3+ years of demonstrated FI experience. No exceptions will be made.

Upon successful completion of all portions of the course, candidates will receive Pro-Board Live Fire Instructor / Instructor In Charge certifications.

Course Schedule (subject to change)

Day 1 Introduction; Chapters 16-18

Day 2 Chapters 19-20; NFPA 1403 Burn Plan Development

Day 3 NFPA 1403 Burn Plan Development; Walk Throughs & Setup

Day 4 Live Fire Evolutions, Skills Testing

Day 5 Demobilization & Cleanup, Survey, and Certification Exam

For more information, please contact Director Jim Graves at 207-844-2078 or jgraves@smccme.edu.

Registration Form

SMCC ID# TODAY’S DATE

LAST NAME FIRST MIDDLE

BIRTH/OTHER NAME E‐MAIL

CELL PHONE HOME PHONE

MAILING ADDRESS

CITY STATE ZIP

COUNTY SOCIAL SECURITY #

GENDER* FEMALE MALE BIRTHDATE* MINOR RELEASE FORM REQUIRED FOR STUDENTS UNDER 18 YEARS OF AGE

ETHNIC GROUP* (CHOOSE ONE) HISPANIC/LATINO NOT HISPANIC/LATINO

RACE* AMERICAN INDIAN OR ALASKA NATIVE ASIAN (CHOOSE ALL THAT APPLY)

BLACK OR AFRICAN AMERICAN WHITE NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

*OPTIONAL – THIS INFORMATION IS USED FOR REPORTING PURPOSES ONLY

YOUR REASON FOR ENROLLING DEGREE OR CERTIFICATE PERSONAL ENRICHMENT TRANSFER TO ANOTHER COLLEGE SKILLS FOR EMPLOYMENT OTHER

I HAVE BEEN A RESIDENT OF MAINE SINCE (for non‐educational purposes) MONTH/YEAR

ARE YOU A U.S. CITIZEN? YES NO PROOF OF MAINE/US RESIDENCY REQUIRED TO QUALIFY FOR IN‐STATE TUITION

DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED? YES NO

REGISTRATION YEAR TERM FALL SPRING SUMMER

COURSE CODE

COURSE NUMBER

COURSE SECTION COURSE TITLE CREDITS

A AUDIT R REPEAT

OFFICIAL USE

Live Fire Training Instructor / Instructor in Charge

STUDENT SIGNATURE

Alabama Fire College, Registration, 2501 Phoenix Drive, Tuscaloosa, Alabama 35405Fax: (205) 391-3758 | Registration@alabamafirecollege.orgLegibly complete form in its entirety- incomplete registration forms will not be processed.

Location of Training Facility/DepartmentCourse Title Begin Date End Date

Individual Information:SSN DOB (MM/DD/YYYY) Gender Previously registered?

M F Yes No

Last Name First Name Middle Name Maiden/Former Name

Street Address City State County Zip Code

HS Diploma/GED? Email Cell Phone Number Work Phone NumberYes No

Department-sponsored information, if applicable:Department sending you for training Training Officer / Fire Chief

Email Cell Phone Number Work Phone Number

Acknowledgments:Hold Harmless: I acknowledge that I could be injured during the training and drills offered to me by the Alabama Fire College. I accept that risk of injury, and in exchange for being allowed to participate in this training and drills, release the Fire College, its instructors, and its employees from any claims for injury.Signature of Student

Honor Statement Policy: During any phase (academic or practical) of an Alabama Fire College course (coursework, evaluation, project, practical/skills exam, cognitive/written exam) cheating, in any form, is prohibited. Cheating, in any form, is acting dishonestly to gain an unfair advantage. Cheating includes but is not limited to: giving or receiving unauthorized aid on any assignment, quiz, or exam; plagiarism, using the ideas of another and declaring it as one’s own; and stealing, taking without permission. During a certification exam, any of the following acts, constitutes academic fraud and could be subject to penalties, including but not limited to, dismissal from and failure of the examination: Looking at another candidate’s exam; Attempting to take an exam for someone else; Attempting to remove an exam from the room in any form; Talking to another candidate; Possession of any device capable of recording or transmitting data, including but not limited to, photography and audio recordings

By checking this box, I acknowledge I have read and understood the Honor Statement Policy.

Course Withdrawal Policy: Students who register for courses and fail to attend will be charged the full registration fee. To receive a full refund, all cancellations or withdrawals must be received in writing to Registration (registration@alabamafirecollege.org) at least two weeks prior to the beginning of class. Students will receive full refunds for courses canceled by the Alabama Fire College.

By checking this box, I acknowledge I have read and understood the Course Withdrawal Policy.

Prerequisite Requirements: Courses may have prerequisites that include either certification or proof of training. Forward all required certificates or proof of training with this registration form. Students not meeting prerequisite requirements will not be certified. Sitting for a test does not guarantee certification. Students not certifying will receive a Certificate of Attendance only. Prerequisites must be a certificate from an agency accredited by either ProBoard or IFSAC. (VA Students must be documented that they meet prerequisites before beginning a class.)

By checking this box, I acknowledge I have read and understood the Prerequisite Requirements.

Felony Conviction Statement: I hereby affirm and certify, under penalty of perjury, that I have not been convicted of a felony and that I am not in violation of Alabama Administrative Code 360-X-1-.01(3)(e)1-2. I attest that all information provided herein is true and accurate to the best of my knowledge.

By checking this box, I acknowledge I have read and understood the Felony Conviction Statement.

Photo Release Statement: I hereby authorize the staff of the Alabama Fire College to use, reproduce, and/or publish photographs and/or video that may pertain to me, including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related marketing endeavors. This material may also appear on the Alabama Fire College’s website and other related social media sites. This authorization is continuous and may only be withdrawn by my specific revocation of this authorization in writing. If I do not wish to agree to this release statement, I will alert my instructor at the beginning of the class as such.

By checking this box, I acknowledge I have read and understood the Photo Release Statement.

(Signature) I attest that the above is true and accurate. Date

COVID-19 Billing ProcedureIn the past, MFSI has collected payment for programs and courses at the time of registration. However, given the increased likelihood of program cancellations due to the ongoing pandemic - and in an effort to avoid delays in departments/individuals/agencies receiving their reimbursement funds for canceled programs - we will not be collecting payment for any program until it has begun.

Please use this form to provide information about the intended payment method (whether it will be an individual or a fire department/other agency) so that MFSI can invoice the payer after the program’s start date. We ask that you write legibly or type your responses. Your application will not be considered complete without this form filled out in its entirety.

Personal checkPayment method*: Purchase order from fire department/municipality

Purchase order number (if applicable):

Payer (name/department name):

Candidate’s name (if different from payer):

Course name: Course location:

Payer’s address for receipt of invoice:

Email address or phone number of payer (not candidate):

This form, and all other registration materials, should be submitted to Anne Heinig at aheinig@smccme. edu or MFSI, ATTN: Anne Heinig, 19 Sewall Street, Brunswick, ME 04011.

If you have any questions about payment options or other billing concerns, please contact Nancy Russell at nrussell@smccme.edu.

*Please note: MFSI cannot accept payments made via credit card.