MAINE FIRE SERVICE INSTITUTE

MAINE FIRE SERVICE INSTITUTE
In Service Since 1948
A program of Southern Maine Community College located at the Midcoast Campus 19 Sewall Street Brunswick ME 04011
207-844-2070
www.MaineFSI.org
NATIONAL FIRE ACADEMY SPRING COURSE SCHEDULE
REGISTRATION MATERIALS PROVIDE AT THE END OF THIS PUBLICATION
REGISTRATION MATERIALS
FIRE INSTRUCTOR I & II
DEADLINE TO REGISTER
FEBRUARY 4, 2015
 SMCC Registration Card
 Check/PO $150 Fee
 FEMA Training Identification
Number
 NFA – General Application
Short Form
MANDATORY ORIENTATION –
MARCH 4, 2014
Class Schedule: Wednesday evening
1800-2100 and 1 Saturday for
presentations TBD.
Class Location: SMCC Midcoast
Campus, Brunswick Me
NFA DIRECT DELIVERY
WEEKEND- MARCH 14 & 15, 2015
 Incident Safety Officer
 Training Operations in Small
Departments
DEADLINE TO REGISTER
JANUARY 15, 2015
 FEMA Training Identification
Number
 NFA - General Application
Short Form
 SMCC Registration Card- No Fee
NATIONAL FIRE
ACADEMY
REGISTRATION
FORMS
AND
INFORMATION
BOOKLET
DOWNLOAD REGISTRATION MATERIALS FROM OUR WEBSITE : WWW.MAINEFSI.ORG /NFA COURSES
Pg 1
This page left blank for printing purposes
For Fire Instructor I & II select pages 3 to 7 for printing
For NFA Weekend at Brunswick Maine select pages 9 to 14 for printing
NFA ENDORSED
FIRE SERVICE
INSTRUCTOR I & II
SPRING COURSE ANNOUNCEMENT
REGISTRATION DEADLINE - PLEASE RESPOND BY FEBRUARY 4, 2015
MAINE FIRE SERVICE INSTITUTE
SMCC MIDCOAST CAMPUS, BRUNSWICK LANDING
Course Description: This 60 + - hour course is designed to meet or exceed Fire Instructor I & II as identified by the National Professional Qualifications Standards. Class
time is spent on instructor roles, audience analysis, communication skills, the writing of
objectives, simulations and evaluation methods. Each student is required to prepare
and deliver both a 10-minute and a 20-minute classroom presentation. Each student
will be provided Jones & Bartlett texts and workbooks. This course requires the use of a
laptop or computer and access to the internet. Some assignments to be completed online.
Recognition /Credit: All students who successfully complete the course of training
will receive a certificate of completion as meeting the NFPA 1041 standard for Fire Service Instructor I & II Professional Qualifications. A minimum of 3 credit hours will be
available to apply to the SMCC Fire Science Technology Degree program per level
awarded. Maine EMS CEH’s may be available along with recognition as an EMS instructor. Check with your regional EMS director for information.
Preferred Prerequisites: NFPA Fire Fighter I and II and 3 years of Fire Service Experience. Only those course participants who meet NFPA Fire Fighter I and II and 3 years of
fire service experience prerequisites will be eligible to participate in the certification
written examination at the end of the course. Copies of your certification will be required
before entry into the certification written exam(s).
This program, once completed, will provide the student with Fire Instructor I & II certification upon the successful completion of the written certification exam(s). Students
are required to attend all class dates scheduled. This course is a very interactive program requiring student presentations. Students are required to speak in front of the
class and will be required to present a lesson to their peers in a 10 minute and then a
20 minute format from a prepared lesson plan. There are weekly quizzes with a final
examination administered by the MFSI Certification Program Manager.
Course Schedule: Orientation March 4th, 2015. Wednesday evenings 1800 2100 with 1 Saturday session 0800 - 1600 (Date TBD at Orientation)
Contact Hours: 60 + /- student hours. Class Size: Minimum 10 students / Maximum 20
students. (First come first served)
Registration fee: $150.00; the registration fee includes a copy of the Jones & Bartlett textbook, and the J&B Workbook. The J&B Exam Prep Book will be provided on a
loan basis to students on request. All checks should be made payable to: SMCC / MFSI.
The SMCC refund policy applies to this course. A $100.00 non-refundable amount is
assessed after attending the Student Orientation.
FMI: Contact James Graves, Deputy Director MFSI 207-844-2078
FIRE
SERVICE
INSTRUCTOR
I & II
2015
MANDATORY
ORIENTATION
MARCH 4, 2015
COURSE SCHEDULE
WEDNESDAY
EVENINGS
1800-2100
1 SATURDAY {TBD}
0800-1600
DEADLINE TO
REGISTER 2/4/2015
REGISTER NOW!
FILL OUT REGISTRATION
MATERIALS INCLUDED.
COST: $150 includes books
MAINE FIRE
SERVICE INSTITUTE
SMCC MIDCOAST CAMPUS
19 SEWALL STREET
BRUNSWICK, ME 04011
Phone: 207-844-2070
Fax: 207-725-9079
E-mail: [email protected]
MFSI Instructors: James Millson and Mark Stevens, Jr.
DEADLINE TO REGISTER IS FEBRUARY 4, 2015
CLASS LOCATION: MFSI, 19 Sewall Street, Brunswick in the Academic Bldg #150
Be sure to fill out the SMCC Registration Form. It is very important to register for your SID number for the
FEMA General Application Forms for each class. Get Instructions here: https://cdp.dhs.gov/elms
These courses are subsidized by the NFA
State Fire Training Grant Fund and the
operating funds provided through the Fire
Investigation and Prevention Tax. (FIPT)
NOTICE TO APPLICANTS FOR FY 2015 NFA ENDORSED COURSES
For FY-2015 NFA on-campus and off-campus courses, you must register for a Student
Identification Number (SID) that will be used in place of the SSN. This number can be obtained
through the Center for Domestic Preparedness (CDP) Training Administration System (CTAS).
Applications for FY-2015 NFA courses that do not include a SID will not be processed.
How do I obtain my FEMA Training Identification Number (FTIN)/CDP Student Identification
(SID) number?
Step 1: To register, go to https://cdp.dhs.gov/elms
Step 2: Click on the “Create Account” button on the left side of the screen.
Step 3: Follow the instructions and provide the necessary information to create your account.
What do I do with this new FTIN/CDP SID number I’ve been assigned?
The CDP SID number should be used in place of the SSN on your General Admissions
Application (FEMA Form 119-25-1) and the General Admissions Application Short Form (FEMA
Form 119-25-2). This number should be used when applying for any FEMA training unless the
SSN is required. FEMA forms are being revised to eliminate the need for the SSN and include a
field for the training registration number.
Why is it important to register in the CTAS?
Any applications for FY 2015 NFA or EMI courses that do not include the training registration
number will not be processed until FTIN/CDP SID is provided.
Application/ Registrations:
A copy of the completed NFA application and course registration are to be completed by the
Student. Incomplete registrations will not be processed. Both of the forms included must be
provided to MFSI no later than February
4, 2015. Spots will be reserved as applications are
received. Space is limited to 20. PLEASE REGISTER EARLY
THERE IS A MATERIALS COST TO ATTEND THESE COURSES. PLEASE REFER TO THE REQUIRED PREREQUISITES
BEFORE REGISTERING. YOU MUST HAVE AS A MINIMUM NFPA FIREFIGHTER I & II AND 3 YEARS OF FIRE SERVICE
EXPERIENCE TO BE ELIGIBLE TO PARTICIPATE IN THE CERTIFICATION WRITTEN EXAMINATIONS AT THE END OF
THE COURSE.
These courses are subsidized by the NFA State Fire Training Grant Fund and the operating funds
provided through the Fire Investigation and Prevention Tax. (FIPT)
Go to https://cdp.dhs.gov/elms GET SID
National Fire Academy Short Form Application 119.25.2 (Complete with SID and signature)
MFSI/SMCC registration form. Yes, we will confirm it via email. Please print legibly.
Mail forms to: MFSI Attn: Anne Heinig 19 Sewall St. Brunswick ME 04011.
DO IT TODAY! DEADLINE IS February 4, 2015. REGISTER NOW!
Check your email for receipt of your registration materials. Mark your Calendars!
DEPARTMENT OF HOMELAND SECURITY
See Reverse for
Privacy Act Statement
FEDERAL EMERGENCY MANAGEMENT AGENCY
GENERAL ADMISSIONS APPLICATION SHORT FORM
O.M.B. No. 1660-0100
Expires August 31, 2013
SECTION I - GENERAL INFORMATION
2. GENDER
1. DATE OF BIRTH (Mo, Day, Yr.)
FEMALE
4. RACE (Please check all that apply)
1.
AMERICAN INDIAN or ALASKAN NATIVE
4.
WHITE
5.
3. U.S. CITIZEN
MALE
2.
YES
ASIAN
NO
3.
PERMANENT
RESIDENT If No, City and Country of Birth:
4a. Ethnicity
BLACK or AFRICAN AMERICAN
HISPANIC or LATINO
NATIVE HAWAIIAN or PACIFIC ISLANDER
NOT HISPANIC or LATINO
5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)
6. STUDENT IDENTIFICATION (SID) NUMBER
7. HOME MAILING ADDRESS (Street, avenue, road no., P.O. box/city or town, and zip code)
8. WORK PHONE NO. (
)
9. HOME PHONE NO. (
)
10. FAX NO. (
)
11. E-MAIL ADDRESS
12a. Enter Course Code and Title
12b. COURSE LOCATION
Y101 & Y102 FIRE SERVICE INSTRUCTOR I & II
12c. DATE
03/04/2015
MAR - JUNE 2015
BRUNSWICK
13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING?
(If yes, indicate & describe any special considerations required on a separate sheet)
NO
YES
SECTION II - EMPLOYMENT INFORMATION
14b. NFIRS #
(NFA ONLY)
14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
16a. JURISDICTION
.1.
STATEWIDE
15. CURRENT POSITION AND NUMBER OF
YEARS IN POSITION
16b. ORGANIZATION
4.
SPECIAL DISTRICT/TOWNSHIP
7.
FOREIGN
1.
ALL CAREER
2.
COUNTY GOVERNMENT
5.
FEDERAL/MILITARY (non-DHS)
8.
DHS/FEMA
2.
ALL VOLUNTEER
3.
CITY/TOWN/VILLAGE
6.
INDUSTRY/BUSINESS
9.
TRIBAL NATION
3.
COMBINATION
16c. CURRENT STATUS
1.
PAID FULL TIME
2.
PAID PART TIME
3.
VOLUNTEER
4.
DISASTER RESERVIST
SECTION III - ENDORSEMENT AND CERTIFICATION
17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001).
17b. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge, or designee, of my organization. All requests for information
shall be in writing from said chief officer or designee.
17c. Further, I understand that the National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC), and the Noble Training Facility (NTF) are not
authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis.
17d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTF. Failure to do so will result in denial of the student stipend, expulsion from the course, and possible barring
from future National Fire Academy (NFA) and Emergency Management Institute (EMI) courses.
18a. SIGNATURE OF APPLICANT
18b. DATE
SIGN HERE
19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS)
By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or disability in providing
educational opportunities for its employees.
19a. SIGNATURE
19b. PRINTED NAME AND TITLE
19c. DATE
MFSI DIRECTOR BILL GUINDON
20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS)
20a. SIGNATURE AND DATE (State Office)
20b. SIGNATURE AND DATE (FEMA Regional Office)
21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR
FEMA Form 119-25-2, (2/12)
PREVIOUS EDITION FF75-5A OBSOLETE
22a. DISPOSITION
ACCEPTED
20b. SIGNATURE OF REVIEWER
22c. DATE
REJECTED
EQUAL OPPORTUNITY STATEMENT
NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, gender, race, color, religious belief, national origin, or disability in their
admissions and student-related procedures. Both schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified
minority and women candidates are encouraged to apply for all courses.
PRIVACY ACT STATEMENT
GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.), Section 552a, for individuals applying for
admission to NFA
Or EMI.
AUTHORITY - Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et. seq.; Robert T. Stafford Disaster Relief and Emergency
Assistance Act, as amended, Title 42 U.S.C., Sections 5121, et. seq.; Title 44 U.S.C. Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Rights
Act of 1964; and Section 504 of the Rehabilitation Act of 1973.
PURPOSES: To determine eligibility for participation in NFA and EMI courses. Information such as age, gender, and ancestral heritage are used for statistical purposes
only.
USES: Information may be released to: 1) FEMA staff to analyze application and enrollment patterns for specific courses, and to respond to student inquiries; 2) a
physician to provide medical assistance to students who become ill or are injured during courses; 3) Members of the Board of Visitors for the purpose of evaluating
programmatic statistics; 4) sponsoring states, local officials, or state agencies to update/evaluate statistics of NFA and EMI participants; 5) Members of Congress seeking
first party information; and 6) Agency training program contractors and computer centers performing administrative functions.
EFFECTS OF NONDISCLOSURE - Personal information is provided on a voluntary basis. Failure to provide information on this form, however, may result in a delay in
processing your application and/or certifying completion of the course.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 6 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing
data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of
information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any
suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency,500 C Street,
SW,Washington,DC,20472, and Paperwork Reduction Project (1670-0100). NOTE: Do not send your completed form to the above address.
Registration Form
MAINE FIRE SERVICE
INSTITUTE
SMCC ID #
TODAY’S DATE
LAST NAME
FIRST
BIRTH/OTHER NAME
E-MAIL
CELL PHONE:
HOME PHONE:
MIDDLE
MAILING ADDRESS
CITY
STATE
COUNTY
SOCIAL SECURITY #
GENDER*
FEMALE
MALE
ETHNIC GROUP* (CHOOSE ONE)
RACE*
ZIP
BIRTH DATE*
HISPANIC/LATINO
NOT HISPANIC/LATINO
AMERICAN INDIAN OR ALASKA NATIVE
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(CHOOSE ALL
ASIAN
WHITE
THAT APPLY)
*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
ARE YOU A U. S. CITIZEN?
YES
/
MONTH/YEAR
NO (PROOF OF MAINE/US RESIDENCY REQUIRED FOR IN-STATE TUITION)
DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED?
REGISTRATION YEAR
TERM:
COURSE
CODE
COURSE
NUMBER
COURSE
SECTION
MFSI
857
01
(FOR NON-EDUCATIONAL PURPOSES)
FALL
YES
NO
SPRING
COURSE TITLE {FILL IN LOCATION OF CLASS}
SUMMER
CREDITS
A AUDIT OFFICIAL
R REPEAT
USE
Fire Service Instructor I & II
YOUR SIGNATURE INDICATES YOU HAVE READ AND UNDERSTAND THE CONDITIONS STATED ON THE BACK OF THIS FORM.
STUDENT SIGNATURE:
Terms & Conditions
Any change in your *credit load may affect your academic standing (program/graduation requirements)
as well as your eligibility for financial aid and/or veterans’ educational benefits. Some MFSI courses
provide academic credit towards the Fire Science Associate Degree Program. For more information,
please contact MFSI at 741-5555.
If you have a disabling condition and wish to request accommodations in order to
have reasonable access to our programs and services, you must register with the ADA
Services Coordinator, Mark Krogman, at 207-741-5629; Maine Relay Service 1-800457-1220.
You are responsible for the financial obligation related to your registered courses. There is a $125.00 fee
for this course. SMCC students who have NOT paid their tuition and fees in full (or enrolled in the College
payment plan) by the due date for the current term risk having their registration canceled.
NATIONAL FIRE ACADEMY
DIRECT TO MAINE FIRE SERVICE
SPRING COURSES
MARCH 14 & 15, 2015
REGISTRATION DEADLINE - PLEASE RESPOND BY JANUARY 15, 2015
Incident Safety Officer (Revised) (F0729)
This 2-day course examines the Safety Officer's role at emergency responses.
A specific focus on operations within an Incident Command System (ICS) as a
Safety Officer is a main theme. Response to all-hazards types of situations will
be emphasized.
Selection Criteria: Individuals who have a Safety Officer responsibility at
emergency operation situations. Persons attending this course should have a
working knowledge of the ICS, as taught by NFA, building construction principles, hazardous materials management, applicable NFPA guidelines, and Federal regulations.
Training Operations in Small Departments (F0290)
This 2-day course is designed to provide students with some basic tools and
skills to coordinate training in a small fire/EMS organization. A training function in a smaller department typically may include conducting training drills
and coordinating training with a nearby larger city or State training function.
Course content includes:
 Leadership issues in fire service training, such as why and how the local
training officer must be a catalyst for change, and personal motivators
within the department.
 Identifying the legal issues affecting the training function, including an
understanding of a standard of care, and the impact of OSHA and NFPA
standards.
 Safety considerations in training.
 Marketing training internally.
 Identifying ways to justify training needs.
 Resolving training conflicts using appropriate conflict resolution techniques
 Selecting and evaluating training curriculum and materials from outside
sources.
 Effective delivery and evaluation of training.
Selection Criteria: Fire and rescue personnel who coordinate training in
small departments.* Volunteer firefighters and officers who instruct in small
fire and rescue departments.* Fire personnel serving on training committees.* Training officers in volunteer fire departments. NOTE: Students who
have taken NFA's Challenges for Local Training Officers through the Volunteer
Incentive Program are not encouraged to take NFA's Training Operations in
Small Departments.
NFA
2015
A strong partnership exists
between NFA and state and
local fire training systems to
advance the professional
development of fire service
personnel. This partnership
has resulted in the ongoing
development and delivery of
the Academy's distance delivery curriculum.
DEADLINE TO REGISTER
JANUARY 15, 2015
REGISTER NOW!
FILL OUT REGISTRATION
MATERIALS INCLUDED.
NO FEE - LUNCH INCLUDED
MAINE FIRE
SERVICE INSTITUTE
SMCC MIDCOAST CAMPUS
19 SEWALL STREET
BRUNSWICK, ME 04011
Phone: 207-844-2070
Fax: 207-725-9079
E-mail: [email protected]
These courses are subsidized by the NFA
State Fire Training Grant Fund and the
operating funds provided through the Fire
Investigation and Prevention Tax. (FIPT)
NOTICE TO APPLICANTS FOR FY 2015 NFA ENDORSED COURSES
For FY-2015 NFA on-campus and off-campus courses, you must register for a Student
Identification Number (SID) that will be used in place of the SSN. This number can be obtained
through the Center for Domestic Preparedness (CDP) Training Administration System (CTAS).
Applications for FY-2015 NFA courses that do not include a SID will not be processed.
How do I obtain my FEMA Training Identification Number (FTIN)/CDP Student Identification
(SID) number?
Step 1: To register, go to https://cdp.dhs.gov/elms
Step 2: Click on the “Create Account” button on the left side of the screen.
Step 3: Follow the instructions and provide the necessary information to create your account.
What do I do with this new FTIN/CDP SID number I’ve been assigned?
The CDP SID number should be used in place of the SSN on your General Admissions
Application (FEMA Form 119-25-1) and the General Admissions Application Short Form (FEMA
Form 119-25-2). This number should be used when applying for any FEMA training unless the
SSN is required. FEMA forms are being revised to eliminate the need for the SSN and include a
field for the training registration number.
Why is it important to register in the CTAS?
Any applications for FY 2015 NFA or EMI courses that do not include the training registration
number will not be processed until FTIN/CDP SID is provided.
Application/ Registrations:
A copy of the completed NFA application and course registration are to be completed by the
Student. Incomplete registrations will not be processed. Both of the forms included must be
provided to MFSI no later than JANUARY
15, 2015. Spots will be reserved as applications
are received. NFA REQUIRES 60 DAY ADVANCE SUBMISSION OF THE ROSTER – WAITING TO
REGISTER MAY CAUSE THE COURSE TO BE CANCELLED IF WE DO NOT MEET THE MINIMUM.
THERE IS NO COST TO ATTEND THESE COURSES. LODGING IS ON YOUR OWN.
BREAKS AND A LUNCH MEAL IS PROVIDED.
These courses are subsidized by the NFA State Fire Training Grant Fund and the operating funds
provided through the Fire Investigation and Prevention Tax. (FIPT)
Go to https://cdp.dhs.gov/elms GET SID
National Fire Academy Short Form Application 119.25.2 (Complete with SID and signature)
MFSI/SMCC registration form. Yes, we will confirm it via email. Please print legibly.
Mail forms to: MFSI 19 Sewall St. Brunswick ME 04011 Attn: Anne Heinig
DO IT TODAY! DEADLINE IS JANUARY 15, 2015. REGISTER NOW!
Check your email for receipt of your registration materials. Mark your Calendars!
DEPARTMENT OF HOMELAND SECURITY
See Reverse for
Privacy Act Statement
FEDERAL EMERGENCY MANAGEMENT AGENCY
GENERAL ADMISSIONS APPLICATION SHORT FORM
O.M.B. No. 1660-0100
Expires August 31, 2013
SECTION I - GENERAL INFORMATION
2. GENDER
1. DATE OF BIRTH (Mo, Day, Yr.)
FEMALE
4. RACE (Please check all that apply)
1.
AMERICAN INDIAN or ALASKAN NATIVE
4.
WHITE
5.
3. U.S. CITIZEN
MALE
2.
YES
ASIAN
NO
3.
PERMANENT
RESIDENT If No, City and Country of Birth:
4a. Ethnicity
BLACK or AFRICAN AMERICAN
HISPANIC or LATINO
NATIVE HAWAIIAN or PACIFIC ISLANDER
NOT HISPANIC or LATINO
5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)
6. STUDENT IDENTIFICATION (SID) NUMBER
7. HOME MAILING ADDRESS (Street, avenue, road no., P.O. box/city or town, and zip code)
8. WORK PHONE NO. (
)
9. HOME PHONE NO. (
)
10. FAX NO. (
)
11. E-MAIL ADDRESS
12a. Enter Course Code and Title
12b. COURSE LOCATION
12c. DATE
MAR 14 & 15, 2015
BRUNSWICK ME
13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING?
(If yes, indicate & describe any special considerations required on a separate sheet)
NO
YES
SECTION II - EMPLOYMENT INFORMATION
14b. NFIRS #
(NFA ONLY)
14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
16a. JURISDICTION
.1.
STATEWIDE
15. CURRENT POSITION AND NUMBER OF
YEARS IN POSITION
16b. ORGANIZATION
4.
SPECIAL DISTRICT/TOWNSHIP
7.
FOREIGN
1.
ALL CAREER
2.
COUNTY GOVERNMENT
5.
FEDERAL/MILITARY (non-DHS)
8.
DHS/FEMA
2.
ALL VOLUNTEER
3.
CITY/TOWN/VILLAGE
6.
INDUSTRY/BUSINESS
9.
TRIBAL NATION
3.
COMBINATION
16c. CURRENT STATUS
1.
PAID FULL TIME
2.
PAID PART TIME
3.
VOLUNTEER
4.
DISASTER RESERVIST
SECTION III - ENDORSEMENT AND CERTIFICATION
17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001).
17b. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge, or designee, of my organization. All requests for information
shall be in writing from said chief officer or designee.
17c. Further, I understand that the National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC), and the Noble Training Facility (NTF) are not
authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis.
17d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTF. Failure to do so will result in denial of the student stipend, expulsion from the course, and possible barring
from future National Fire Academy (NFA) and Emergency Management Institute (EMI) courses.
18a. SIGNATURE OF APPLICANT
18b. DATE
SIGN HERE
19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS)
By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or disability in providing
educational opportunities for its employees.
19a. SIGNATURE
19b. PRINTED NAME AND TITLE
19c. DATE
MFSI DIRECTOR BILL GUINDON
20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS)
20a. SIGNATURE AND DATE (State Office)
20b. SIGNATURE AND DATE (FEMA Regional Office)
21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR
FEMA Form 119-25-2, (2/12)
PREVIOUS EDITION FF75-5A OBSOLETE
22a. DISPOSITION
ACCEPTED
20b. SIGNATURE OF REVIEWER
22c. DATE
REJECTED
EQUAL OPPORTUNITY STATEMENT
NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, gender, race, color, religious belief, national origin, or disability in their
admissions and student-related procedures. Both schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified
minority and women candidates are encouraged to apply for all courses.
PRIVACY ACT STATEMENT
GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.), Section 552a, for individuals applying for
admission to NFA
Or EMI.
AUTHORITY - Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et. seq.; Robert T. Stafford Disaster Relief and Emergency
Assistance Act, as amended, Title 42 U.S.C., Sections 5121, et. seq.; Title 44 U.S.C. Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Rights
Act of 1964; and Section 504 of the Rehabilitation Act of 1973.
PURPOSES: To determine eligibility for participation in NFA and EMI courses. Information such as age, gender, and ancestral heritage are used for statistical purposes
only.
USES: Information may be released to: 1) FEMA staff to analyze application and enrollment patterns for specific courses, and to respond to student inquiries; 2) a
physician to provide medical assistance to students who become ill or are injured during courses; 3) Members of the Board of Visitors for the purpose of evaluating
programmatic statistics; 4) sponsoring states, local officials, or state agencies to update/evaluate statistics of NFA and EMI participants; 5) Members of Congress seeking
first party information; and 6) Agency training program contractors and computer centers performing administrative functions.
EFFECTS OF NONDISCLOSURE - Personal information is provided on a voluntary basis. Failure to provide information on this form, however, may result in a delay in
processing your application and/or certifying completion of the course.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 6 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing
data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of
information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any
suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency,500 C Street,
SW,Washington,DC,20472, and Paperwork Reduction Project (1670-0100). NOTE: Do not send your completed form to the above address.
Registration Form
MAINE FIRE SERVICE
INSTITUTE
SMCC ID #
TODAY’S DATE
LAST NAME
FIRST
BIRTH/OTHER NAME
E-MAIL
CELL PHONE:
HOME PHONE:
MIDDLE
MAILING ADDRESS
CITY
STATE
COUNTY
SOCIAL SECURITY #
GENDER*
FEMALE
MALE
ETHNIC GROUP* (CHOOSE ONE)
RACE*
ZIP
BIRTH DATE*
HISPANIC/LATINO
NOT HISPANIC/LATINO
AMERICAN INDIAN OR ALASKA NATIVE
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(CHOOSE ALL
ASIAN
WHITE
THAT APPLY)
*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
ARE YOU A U. S. CITIZEN?
YES
/
MONTH/YEAR
NO (PROOF OF MAINE/US RESIDENCY REQUIRED FOR IN-STATE TUITION)
DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED?
REGISTRATION YEAR
(FOR NON-EDUCATIONAL PURPOSES)
TERM:
FALL
YES
NO
SPRING
COURSE
CODE
COURSE
NUMBER
COURSE
SECTION
MFSI
NFA
01
INCIDENT SAFETY OFFICER {FO729}
MFSI
NFA
02
TRAINING OPERATIONS IN SMALL DEPTS {FO290}
COURSE TITLE {FILL IN LOCATION OF CLASS}
SUMMER
CREDITS
A AUDIT OFFICIAL
R REPEAT
USE
YOUR SIGNATURE INDICATES YOU HAVE READ AND UNDERSTAND THE CONDITIONS STATED ON THE BACK OF THIS FORM.
STUDENT SIGNATURE:
Terms & Conditions
Any change in your *credit load may affect your academic standing (program/graduation requirements)
as well as your eligibility for financial aid and/or veterans’ educational benefits. Some MFSI courses
provide academic credit towards the Fire Science Associate Degree Program. For more information,
please contact MFSI at 741-5555.
If you have a disabling condition and wish to request accommodations in order to
have reasonable access to our programs and services, you must register with the ADA
Services Coordinator, Mark Krogman, at 207-741-5629; Maine Relay Service 1-800457-1220.
You are responsible for the financial obligation related to your registered courses. There is a $125.00 fee
for this course. SMCC students who have NOT paid their tuition and fees in full (or enrolled in the College
payment plan) by the due date for the current term risk having their registration canceled.