Citizens Fire Academy Application
Please indicate to which year you are applying.
General Information
Name:
(Last Name, First, Middle)
Other Names Used:
(i.e. Maiden, AKAs, previous married names etc.)
Social Security Number: Date of Birth:
Home Address:
Home Telephone: Work Telephone:
Email Address:
Driver’s License Number and State:
License currently valid? YES NO
Emergency Information
Please indicate the person we should contact in the event of a medical emergency:
Name: Relationship:
Home address:
Home Phone: Alternate Phone:
YES NO Have you ever been arrested or convicted for a felony?
YES NO Are you currently under indictment or charged with any criminal offense?
YES NO Are you currently on probation or parole?
If Yes was selected for any of the above three questions please explain when, where, what charge
and the disposition of the case(s).
2018
How did you hear about the Kannapolis Citizens Fire Academy?
How do you feel the Citizens Fire Academy will benefit you?
YES NO Are you at least 18 years of age?
YES NO Do you currently live and/or work in the City of Kannapolis?
I certify that all statements made on this application are true and complete. I authorize any individual,
company, organization or institute to release any and all information concerning statements made by
me on this application. I agree and understand that any deliberate misstatements or omissions of
materials facts will disqualify me to attend and/or participate in the Kannapolis Citizens Fire Academy.
My signature below acknowledges my understanding and agreement with materials provided.
________________________________________ ______________________
Signature Date
Please mail completed application and release of liability to:
Kannapolis Fire Department
401 Laureate Way,
Kannapolis, NC 28081
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KANNAPOLIS CITIZENS FIRE ACADEMY
PARTICIPANT WAIVER AND RELEASE
The representatives of the City of Kannapolis have informed me that portions of the program in which I seek to
participate are physically challenging and may involve use of fire fighting equipment and/or the operation of a
fire vehicle and that there is some risk inherent with participation in this program to both participants and
observers. Accordingly, in consideration for my participation in the program, I expressly acknowledge and
agree to the following:
I recognize that the potential for injury exists and that participation in fire fighting activities entails both known
and unanticipated risks which could result in physical or emotional injury, paralysis, death, or damage to
myself, to personal property, or to third parties.
I understand that such risks cannot be eliminated without jeopardizing the essential qualities of this activity,
and freely assume the same. These risks, include, among other things, the potential for slips, falls and falling,
bites, pinches, scrapes, twists and jolts that could result in scratches, bruises, sprains, lacerations, fractures,
concussions or even more severe life threatening hazards.
At any time, I am free to withdraw from participation in physical activities, whether I do so individually or as part
of a group. The decision to continue participation in an activity indicates my consent and continue release of
liability. I expressly agree and promise to accept and assume all of the risks existing in this activity.
I acknowledge that employees of Kannapolis and their representatives or agents have a difficult job to perform
in providing fire fighting and driving facilities, and recognize that while they seek safety, they are not infallible.
They may be unaware of physical or mental conditions of mine or other participants or our fitness to participate
in this program. Recognizing this, I release the City of Kannapolis, its agents, officers, volunteers, participants,
employees and all other persons or entities acting in any capacity on their behalf (herein after referred to as
Kannapolis) from any and all liability or responsibility for any claims, demands or causes of action in any way
connected with my participation in any activity held on municipal or third party properties, including the Rowan
Cabarrus Community College (RCCC) Burn Building, and specifically including any such claims which
allege negligent acts or omissions of Kannapolis. I further agree to hold harmless, release, indemnify and
discharge Kannapolis from any such demands or claim on behalf of myself, my children, my parents, my
spouse, my heirs, assigns, personal representatives and estate.
Should Kannapolis or anyone acting on either of Kannapolis behalf be required to incur attorney’s fees and/or
costs to defend claims made by made or on my behalf or to otherwise enforce this agreement, I agree to
indemnify and hold them harmless for all such fees and costs.
I certify that I have adequate insurance, either personally or through my employer, to cover any injury or
damage that I may cause or suffer while participating in activities on municipal or third party properties, I agree
to bear the costs of such injury or damage myself.
I agree not to be under the influence of any chemical substance or alcohol during my participation in this
activity and to abide by the rules established by Kannapolis while attending and participating in this activity.
If the program coordinator(s) recommend that I limit my participation in the physical activity portions of this
activity and I choose not to do so, I agree that by such action on my part I waive all claims I may have against
Kannapolis for any and all injuries or damages suffered by me during the activity, including claims of gross
negligence or willful misconduct.
In case of accident, Kannapolis and its agents have my consent to release all information and incident reports,
including medical information, to insurance companies or other agencies deemed appropriate by the City.
I authorize Kannapolis, its agents or other emergency medical personnel to render emergency or first aid
treatment for any and all illnesses or injuries to me.
I represent that I am over eighteen (18) years of age, am under no physical or mental disability which affects
my ability to make responsible decisions, and that I have the authority to enter into this agreement.
I represent that I have fully disclosed any medical conditions that I may have which could affect my fitness to
participate in this activity, and in my opinion it is safe for me to proceed with participation.
I have had sufficient opportunity to read this entire document, and understand the contents. I
agree to be bound by the terms stated herein.
Executed as a free and voluntary act if the undersigned this day of , 20
Participant’s Name: (Print)
Participant’s Address
Home Telephone: Work Telephone:
Email address:
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ___ day of ________________
in the year ______.
_____________________________________________
Applicant Signature
STATE OF NORTH CAROLINA
COUNTY OF: ________________________
I, _______________________________________, a Notary Public in and for said county and state, do hereby certify that
_________________________________________ personally appeared before me this day and acknowledged the due
execution of the foregoing instrument.
Witness my hand and seal this the _____ day of ________________________ in the year __________.
My Commission Expires: __________________________________
Notary Public: ___________________________________________
Signature
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