Fillable CCAI Fire Pre Apprenticeship Fillable (Columbia College)

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CCAI Fire Pre Apprenticeship Fillable (Columbia College)

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Columbia College
Fire Science
Pre-Apprenticeship
Initiative Application
The Columbia College Fire Science Pre-Apprenticeship Initiative is a grant funded program. Its mission is to
provide students in the program an introduction to a variety of careers in fire science through hands-on
experiences, workshops, field trips, job shadowing, and more.
If you have any questions please contact Jen Bick at 209-588-5269 bickj@yosemite.edu
PLEASE PRINT CLEARLY (All information will be kept confidential)
Contact Information
Name:
Address:
Number and street
City
State
Zip
E-mail:
Home phone: Cell:
Best Time
to call:
Uniform Shirt Size: (circle one) S M L XL
2XL 3XL
How did you learn about this program?
Year of high school graduation: or Year of GED:
Have you completed college units?
Yes
No
Colleges/Universities attended (names/dates):
If yes, how many?
What are your educational goals? (circle ALL that apply)
Certificate Associate’s Degree
Bac
helor’s Degree Undecided
Read, Sign and Date.
I verify that the information on this form is correct and complete.
___________________________________
Student Signature
______________________________
Date
__________
_________________________
Parent/Guardian Signature
(required for all students under 18 years of age)
_______
_______________________
Date
Submit application electronically to: Jen Bick, bickj@yosemite.edu or mail to CCAI: 11600 Columbia College Dr, Sonora, CA 95370
COLUMBIA COLLEGE PRE-APPRENTICESHIP INITIATIVE
INSTRUCTIONS: Use a pen with black or blue ink to complete this form. For multiple choice questions, make heavy dark
marks that fill each square completely.
1. _________________ ______ ______________________
First Name MI Last Name
2. Today’s Date: | _ | _ |/| _ | _ |/| 2 | 0 | 1 |
|
Month Day Year
2. Date of Birth: | | | / | | | / | | | | |
Month Day Year
3. Gender:
1 □ Male
2 □ Female
4. Are you of Hispanic or Latino heritage?
1 □ Yes
0 □ No
5. What is your race?
PLEASE CHECK ALL THAT APPLY
1 □ African American/Black
2 □ American Indian/Alaska Native
3 □ Asian
4 □ Native Hawaiian/Other Pacific Islander
5 □ White
6 □ Some Other Race (Write in):_____________________
6. What is the MAIN language you speak at home?
MARK ONE BOX
1 □ English
2 □ Spanish
3 □ Another language (specify ):
7. What is the highest level of education you have achieved?
1 □ Did not complete High School
4 □ HS Diploma
5 □ GED
6 □ College Certificate (i.e. less than 2 year certificate)
7 □ Associate’s degree (AA/AS)
8 □ Bachelor’s degree (BA/BS)
9 □ Graduate degree
10 □ Other (Write in):____________________
8. Do you have a disability?
1 □ Yes, I have a disability
0 □ No, I do not have a disability
9. Have you served on Active Duty (other than reserve status)
in the U.S. Armed Forces?
1 □ Yes
0 □ No
10. Please check each of the following sources of assistance that
anyone in your household received in the past month.
MARK ALL THAT APPLY
1 □ TANF (Cash assistance)
2 □ SSI or SSDI
3 □ General Relief
4 □ SNAP (Food Stamps)
5 □ Unemployment Compensation
6 □ Other (Write in):
0 □ IF NONE, MARK HERE
Course Enrolled: Columbia College Fire Science Pre-Apprenticeship Semester: __________________
AGREEMENT AND RELEASE OF LIABILITY
This agreement is between: (Student) ______________________________________________________
________________________________________,______________________, _________, ____________
Address City State Zip
In the event that we need to get a hold of you today, please provide your cell number __________________________
And Yosemite Community College District and its instructors, members, agents, authorized guests and affiliated organizations.
In consideration for enrollment in one or more programs offered by the Columbia College Fire Science Pre-Apprenticeship.
I make the following statements and promises:
I am aware that Fire Science Pre-Apprenticeship activity classes may involve strenuous physical activity and that I will be
practicing and/or performing in situations that maybe demanding and/or stressful.___________ Initial
I am voluntarily taking these classes with knowledge of the risk involved, and I agree to accept any and all risk of injury that may
occur in the normal cause of events. ___________ Initial
If I have a disability or illness, I promise to consult with my attending health care provider before taking the above instruction.
___________ Initial
I agree that I, my heirs, legal representatives and assigns do hereby agree to:
1. NOT make claims against Yosemite Community College District and or the Instructor (individually or collectively) for
any damage to myself or another resulting from my participation in this or any other program offered by Yosemite
Community College District, __________, and Initial
2. Waive, release, and discharge Yosemite Community College District and or Fire Science Pre-Apprenticeship Instructor
from all claims or demands arising from injury or damage to myself or another caused by my participation in this
program offered by Yosemite Community College District, Columbia College Fire Science Pre-Apprenticeship.
___________ Initial
I promise to defend, indemnify, and hold harmless Yosemite Community College District, Columbia College Fire Science Pre-
Apprenticeship and Fire Science Pre-Apprenticeship Instructors from any claims and actions by third parties alleging injury from
my participation in the programs. __________ Initial
I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a
contract between myself and Yosemite Community College District, Columbia College Fire Science Pre-Apprenticeship, and sign
it of my own free will.
_____________ _____________________________________________
Date Signature
_________________
______________________________________________________________
Date Signature of parent or legal guardian if under 18 years of age
In case of an emergency please contact _________________________________ Phone Number__________________
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CCAI Fire Pre Apprenticeship Fillable (Columbia College)

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Completed 19 July 2020

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