Meriden Fire Department Citizen’s Fire Academy Application
Last Name: _________________ First Name: _______________ Middle Initial: ______
Address:_______________________________________________________________
City: ___________________________ State: _________ Zip Code: ______________
Home Phone: ____________________________ Cell Phone: ____________________
Email Address: ___________________________
Date of Birth: ____________________ Sex: (M/F) ________ Race: __________
Drivers License #: ________________ State Issued: _________________________
Employer: ______________________________ Occupation: ________________
Employer Address: ______________________________________________________
Work Phone: ____________________________ Shirt Size:
______________
Any known medical conditions:
_____________________________________________________________________
_____________________________________________________________________
Do you have any severe limitations that would hinder you from engaging in activities
associated with the Citizen’s Fire Academy? Yes ____ No ____ If yes, please explain:
______________________________________________________________________
______________________________________________________________________
Any known allergies:
______________________________________________________________________
Emergency Contact Name: ________________________________________________
Emergency Contact Phone: ____________________ Relationship: ________________
Why do you wish to attend the Citizen’s Fire Academy?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you ever been convicted of a felony? Yes ______ No ______ If yes, please
explain
______________________________________________________________________
______________________________________________________________________
I am willing to undergo a minimum background investigation by the City of Meriden due
to sensitivity and nature of some of the information that will be covered during the
course of the Citizen’s Fire Academy. Yes ______ No ______
Please submit to: Division Chief Michael Shaw
Meriden Fire Department
Station 1
168 Chamberlain Highway
Meriden, CT 06451
For information, please contact: Division Chief Michael Shaw 203-530-3668
Please fill out the application and sign the waivers and return to the information
provided above.
MERIDEN FIRE DEPARTMENT CITIZEN’S ACADEMY
PARTICIPATION RELEASE
The City of Meriden (CITY), on condition of agreeing to the terms and conditions of the Participant
Release set out below, agrees to permit you to participate in the Citizen’s Fire Academy.
WAIVER RELEASE
I, __________________________________, acknowledge that my participation in the Citizen’s Fire
Academy is voluntary. I further acknowledge that my participation in the Citizen’s Fire Academy entails
known and unanticipated risks that could result in physical or emotional injury to me or to third parties or
damage to my property or that of the CITY or third parties.
I DO HEREBY KNOWINGLY ASSUME ALL RISKS, KNOWN AND UNANTICIPATED, ASSOCIATED
WITH PARTICIPATION IN THE ACTIVITY, FULLY REALIZING THAT IN SO DOING I MAY EXPOSE
MYSELF TO THE EXTRAORDINARY DANGERS AND HAZARDS WHICH MAY ARISE IN
CONNECTION THEREWITH, AND DO HEREBY RELEASE AND FOREVER DISCHARGE THE CITY, A
MUNICIPAL CORPORATION, ITS SUCCESSORS, ASSIGNS, OFFICERS, AGENTS, SERVANTS, AND
EMPLOYEES FROM ANY AND ALL CLAIMS, DEMANDS, DAMAGES, ACTIONS, AND CAUSES OF
ACTIONS, WHATSOEVER, WHETHER SUCH ARE FOUNDED IN WHOLE OR IN PART UPON THE
ALLEGED NEGLIGENCE OF THE CITY, ITS AGENTS OR EMPLOYEES, WHICH I, MY HEIRS, OR
PERSONAL REPRESENTATIVES MAY EVER HAVE ARISING OUT OF, BY REASON OF, OR IN ANY
MANNER HAVE GROWN OUT OF ANY INJURIES OR DAMAGES SUSTAINED BY ME BY REASON
OF ANY ACCIDENT OR OTHER OCCURRENCE RESULTING FROM PARTICIPATION IN THE
ACTIVITY.
In signing this release, I am relying wholly upon my own judgment, belief, and knowledge. By signing this
document, I acknowledge that if anyone is hurt or property is damaged during my participation in the
Citizen’s Fire Academy, I may be found by a court of law to have waived my right to maintain a lawsuit
against the CITY on the basis of any claim from which I have released the CITY herein. I have had
sufficient opportunity to read this entire document. I read and understand it, and I agree to be bound by its
terms.
Signature ________________________________ Date ______________________________
__________________________________________________________________________________
Address
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signature
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________________________________________
Telephone Number
Meriden Fire Department Photograph & Video Release Form
I, ______________________________________, hereby grant the Meriden Fire
Department permission to the rights of my image, likeness and sound of my voice as
recorded on audio or videotape without payment or any other consideration. I
understand that my image may be edited, copied, exhibited, published or distributed
and waive the right to inspect or approve the finished product wherein my likeness
appears. Additionally, I waive any right to royalties or other compensation arising or
related to the use of my image or recording.
By signing this release I understand this permission signifies that photographic or video
recordings of me may be electronically displayed via the Internet or in the public setting.
There is no time limit on the validity of this release nor is there any geographic limitation
on where these materials may be distributed.
By signing this form I acknowledge that I have completely read and fully understand the
above release and agree to be bound thereby. I hereby release any and all claims
against any person or organization utilizing this material.
______________________________________________________________________
Signature Date
______________________________________________________________________
Address
___________________________________
Telephone Number
click to sign
signature
click to edit
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