BERRIEN COUNTY FIRE FIGHTERS TRAINING COMMITTEE

FIRE FIGHTER 1 & 2Registration Packet

RETURN YOUR COMPLETED APPLICATION TO:Mail: Berrien County Fire Fighters Training Committee, P.O. Box 214, Berrien Springs, MI 49103 Scan and e-mail: bcfftc1@gmail.com

MINIMUM PRE-REQUISITES AND ADMISSION CRITERIA: Must be turned in prior to Orientation. Must be 18 to enter the course High school diploma or equivalent Current valid driver's license (faxed copies will not be accepted) Completed and signed application for admission Firefighter Medical Exam form signed by a licensed physician, or such physician's designee within the past 12 months Tetanus/Booster cannot be over 10 years old. (Must have full date) BCFFTC Physical Statement form signed by a LICENSED PHYSICIAN within the last 12 months. Must have

licensed physician signature or such physician's designee.

REGISTRATION PAYMENT POLICY:Official registration requires full payment of $250.00 by check at the time of registration. Checks are to be made payable to: BCFFTC , P.O. Box 214, Berrien Springs, MI 49103

REFUND POLICY:There are no refunds on registration fees for students who register for a course and wish to withdraw from course.

CANCELLATION POLICY:The Berrien County Fire Fighters Training Committee reserves the right to cancel or postpone any class.All accommodations will be made to make a class up.

FIRE CHIEF’S RESPONSIBILITY:Fire Chief will remit the application and the physical statement (signed by a physician) to the Berrien County Fire Fighters Training Committee. Fire Chief will also register Fire Fighter on the Michigan Fire Fighter Training Committee website (SMOKE). Fire Chief and Fire Fighter must sign the Student Accountability Form and return to the Berrien County Fire Fighters Training Committee on first night of class.

Course #’s in SMOKE: 2019-2-11-A25D-0008 FF 1&2

2019-2-11-L13B-0008 Incident Command and Resource Management for the Fire Service

2019-2-11-B05D-0019 VFIS Drivers Training (Classroom Only)

Berrien County Fire Fighters Training Committee Send documents to: BCFFTC, P.O. Box 214, Berrien Springs, MI 49103 Phone: (269)363-1316

bcfftc1@gmail.com Students with incomplete registration forms will not be allowed in class. Legibly complete form in its entirety.

1. Department: 2. Course Title: FF 1&2

3. Begin Date:10/6/18

4. End Date:5/11/18

5.MFFTC PIN: 6. Gender:

Male Female7. Last Name: 8. First Name: 9. Middle Name: 10. Suffix: 11. Email:

12. Street Address: 13. City: 14. State: 15. Zip: 16. County:

17. Contact Number: 18. Work Number:

19. Training Officer/Fire Chief’s information:

Name (Print):

20. Office Number: 21. Cell Number: 22. Training Officer/Chief’s email address

23. Training Officer/Fire Chief’s Signature:

Honor Statement Policy: During any phase (academic or practical) of a Berrien County Fire Fighters Training Committee 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 audioBy 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. This is a non-refundable class.

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.

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. 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 Berrien County Fire Fighters Training Committee 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 Berrien County Fire Fighter Training Committe’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.

By checking this box, I acknowledge and agree that my academic information may be shared with the Department Chief or Training Officer.

(Signature) I attest that the above is true and accurate. DateAn electronic signature will be considered as legally binding as a document signed in ink.

Revised 7/20/18

BERRIEN COUNTY

FIRE FIGHTER TRAINING COMMITTEE P.O. BOX 214 • BERRIEN SPRINGS • MI • 49103 • (269) 363-1316

BERRIEN COUNTY FIRE FIGHTER 1&2 CLASSSTUDENT EXPECTATIONS

1. Be to class ON TIME!

2. Sign the attendance sheet every class. If you do not sign in, you are considered absent.

3. Food and/or drinks may be brought to class, however, you are responsible for keeping the classroom clean.

4. Classroom attendance is 95%. If you miss a classroom session, you MUST turn in a make –up assignment approved by the Training Committee.

5. Practical skills attendance is 100%. If you miss a practical session, you MUST make arrangements to make up the class with a member of the Training Committee.

6. Students SHALL be clean shaven at all sessions (classrooms & practicals).

7. Turnout gear SHALL be brought to ALL classes per the schedule. Turnout gear WILL NOT be worn in the classroom area. Gear will be placed in the apparatus room, clear of all doors, walkways and fire apparatus.

8. Pagers, radios, phones, etc. SHALL be turned off during class & practical sessions.

9. NO PHOTO’s are to be taken during any class time.

10. Alcohol and/or drugs WILL NOT be tolerated at any session. We are a ZERO TOLERANCE facility. Students WILL be expelled permanently, if determined to be under the influence.

11. No tobacco products of any kind are allowed at any training session (classroom or practical).

12. Uniforms of the Day will consist of Department T-shirt/Station wear, Class A or B Uniform or T-shirts provided by the BCFFTC. NO inappropriate clothing will be allowed during class time (including torn/ripped pants, torn/ripped shirts, tank tops, etc.). NO hats are allowed to be worn during classroom sessions.

A violation of any of the above will result in a letter being sent to your Chief. You MAY be expelled from the course.

***I HAVE READ THE ABOVE RULES AND WILL ADHERE TO ALL EXPECTATIONS***

Print Name: ___________________ Signature: ___________________ Date: _________ (Student) (Student)

Print Name: ____________________ Signature: __________________ Date: _________ (Chief) (Chief)

Note to applicant: Both pages of the following form must be completed and forwarded to Berrien County Fire Fighters Training Committee within

30 DAYS from start of class.

PHYSICAL STATEMENTThe Physical and Medical examination should be conducted for the purpose of detecting or determining the presence of deficiencies or abnormalities which would reasonably be expected to limit the abilities of the applicant to satisfactorily and safely perform all the duties associated with firefighting (as outlined in NFPA 1582).

The Essential Functions of Firefighting listed below are meant to serve as a reference resource for physicians when determining the fitness of a candidate for firefighting duties. The Essential Functions of Firefighting are meant to define and to give a broader understanding of the physical requirements demanded of firefighters. The Essential Functions of Firefighting are merely meant to be used as an aid for physicians when determining the physical status of a candidate.

Essential Functions of Firefighting, Based on NFPA 1582

Performing fire-fighting tasks (e.g., hose line operations, extensive crawling, lifting and carrying heavy objects, ventilating roofs or walls using power or hand tools, forcible entry), rescue operations, and other emergency response actions under stressful conditions while wearing personal protective ensembles and self-contained breathing apparatus (SCBA), including working in extremely hot or coldenvironments for prolonged time periods

Wearing a SCBA, which includes a demand valve–type positive-pressure face piece or HEPA filter masks, which requires the ability to tolerate increased respiratory workloads

Exposure to toxic fumes, irritants, particulates, biological (infectious) and nonbiological hazards, and/or heated gases, despite the use of personal protective ensembles and SCBA

Depending on the local jurisdiction, climbing six or more flights of stairs while wearing fire protective ensemble weighing at least 50 lb (22.6 kg) or more and carrying equipment/tools weighing an additional 20 to 40 lb (9 to 18 kg)

Wearing fire protective ensemble that is encapsulating and insulated, which will result in significant fluid loss that frequently progresses to clinical dehydration and can elevate core temperature to levels exceeding 102.2°F (39°C)

Searching, finding, and rescue-dragging or carrying victims ranging from newborns up to adults weighing over 200 lbs. (90 kg) to safety despite hazardous conditions and low visibility

Advancing water-filled hose lines up to 21/2 in. (65 mm) in diameter from fire apparatus to occupancy [approximately 150 ft. (50 m)], which can involve negotiating multiple flights of stairs, ladders, and other obstacles

Climbing ladders, operating from heights, walking or crawling in the dark along narrow and uneven surfaces, and operating in proximity to electrical power lines and/or other hazards

Unpredictable emergency requirements for prolonged periods of extreme physical exertion without benefit of warm-up, scheduled rest periods, meals, access to medication(s), or hydration

Operating fire apparatus or other vehicles in an emergency mode with emergency lights and sirens

Berrien County Fire Fighters Training Committee

Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous environments, including hot, dark, tightly enclosed spaces, that is further aggravated by fatigue, flashing lights, sirens, and other distractions

Ability to communicate (give and comprehend verbal orders) while wearing personal protective ensembles and SCBA under conditions of high background noise, poor visibility, and drenching from hose lines and/or fixed protection systems (sprinklers)

Functioning as an integral component of a team, where sudden incapacitation of a member can result in mission failure or in risk of injury or death to civilians or other team members

I have examined __________________________Applicant’s Full Name – Print

and as a physician licensed to practice or such designee do hereby certify that the applicant is in good health and physically fit for the performance of the duties of a firefighter as outlined in NFPA 1582.

Last 4 digits of Applicant’s SSN: _ __ __ __

Physician’s Signature Date of Examination

Physician’s Name – Printed

Name of Practice

Address

_____________________________________________________________ _____ __________________ City State Zip Code

Office Phone

FIREFIGHTER Medical Exam Form Must be completed and signed by a licensed physician or such physician's designee by October 1, remitted to sponsoring Fire

Department

Name: Height: ' ”

Weight: lbs. Student is able to send verbal messages yes no

Vision Status: Right Eye: 20/

Left Eye: 20/ Corrected:

Blood Pressure: / Pulse Rate: Normal Abnormal If abnormal, explain

1.Skin 2.Head & Neck 3.Eyes 4.Ears, Nose, Throat 5.Teeth & Mouth 6.Lungs & Chest 7.Cardiovascular 8.Abdomen & Lymphatics 9.Genitalia/Hernia 10.Orthopedic Screening:

a.Upper Extremities b.Lower Extremities c. Spine & Back

11.Neurological

12. Tests and/or Vaccinationsa. Tetanus/Booster: Administered

Date / / (Cannot be over 10 years old)

b. Hepatitis: Shot Dates:

1. / / 2. / / 3. / /

: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Note: The student has provided me a copy of the “Essential Functions” for the program and he or she is able to perform these functions.

This is to certify that on this _______ day of ____________, 20____, I performed the above limited

examination of __________________________ and based upon the medical history given, and upon my evaluation, I am of the opinion that he/she IS_____ IS NOT_____ able to participate in the Berrien County FireFighters Training Committee Fire Fighter 1&2 Class.

Printed Name: _______________________ Signature: _______________________ (Physician or designee) (Physician or designee)

Date: _______________