Fillable FIRE HAWK APPLICATION (Mohawk Valley Community College)

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FIRE HAWK APPLICATION (Mohawk Valley Community College)

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  • 10 check-boxes
  • 127 other fields

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Revised 5/13/16 by MVCC
Page1
FIRE HAWK APPLICATION
Checklist
Applications Are Due no Later than:
July 15 – For Fall Admission (August start)
November 10 – For Spring Admission (January start)
__________________________________________________________________________________
Use this checklist to insure that you have filled out all required forms and completed the necessary steps
for consideration of a Fire Hawk Scholarship. Retain this checklist and a copy of all of your application materials
for your own records.
First Steps:
1. Apply to MVCC by completing the Application for Admissions (either online at www.mvcc.edu
or in paper format). If you have questions about your application status, call the Admissions
Office at 315-792-5640. Remember to request your high school transcript be sent to the MVCC
Admissions Office or if you have a GED, please submit a copy to Admissions.
2. Complete the financial aid process by completing the current FAFSA and TAP application
(https://fafsa.ed.gov). If you have any questions, call the Financial Aid Office at 315-792-5415. (Please
note that if you are eligible for Pell and TAP that will be applied to your tuition and fees first. If you are
awarded a Fire Hawk Scholarship, that will be applied to any remaining balance for tuition and fees. The
Fire Hawk Scholarship does not cover books nor room and board.
Please contact Kevin Siembab at 315-792-5502 or ksiembab@mvcc.edu, with any questions or if you need
assistance
with the enrollment process. Mr. Siembab will guide you step by step through the enrollment process.
Fire Hawk Application Checklist:
□ Complete Fire Hawk Application (Page 2)
□ Volunteer Service Agreement — Sponsoring Agency form completed and signed by your chief. (Page 3)
□ Complete, sign, and date the Volunteer Service Agreement—Volunteer form. (Page 4)
□ Have your chief complete, sign, and date the Sponsoring Agency Verification & Tracking form.(Page 5)
□ Read, complete, sign, and date the Certification of Information/FERPA—Release of Academic and Financial
Records form. (Page 6)
□ Complete, sign, and date the 2-page Letter of Reference form for each person you are asking to recommend you
and obtain the completed forms from each person. (Pages 7-8)
□ Make a copy of the entire application for your own records.
□ Drop off or mail (postmarked by the deadline date) the completed Fire Hawk application packet to:
Kevin Siembab
Career Services/Alumni College Center, Room 102
Mohawk Valley Community College
1101 Sherman Drive
Utica, NY
13501
Revised 5/13/16 by MVCC
Page2
FIRE HAWK APPLICATION
Name: ___________________________________________________________________________
Address:__________________________________________________________________________
Ci
ty: __________________________ State: ________________________ Zip Code: __________
Phone: Home _________________ Work __________________ Cell ____________________
Email: ____________________________________________________________________________________
Sponsoring Agency: ________________________________________________________________
Fire Chief: ________________________________________________________________________
Date Joined: _______________________________________________________________________
Pl
ease name the program you are in enrolled in at MVCC: ________________________________
Pl
ease check the appropriate line below:
_____Degree _____Certificate Program
Pl
ease check your enrollment status below:
_____Full-Time (12 credits or more) _____Part-Time (6 to 11 credits)
Explain how this program fits with your own educational, professional, and/or personal goals
(Please feel free to attach a separate sheet of paper, if necessary.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Describe your plan for balancing commitments at home, work, school, and the sponsoring agency
(Please feel free to attach a separate sheet of paper, if necessary.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Note: It is the responsibility of the Fire Hawk scholarship recipient to provide all required materials to the
appropriate people by the deadlines set in order to remain eligible for continued sponsorship. This includes,
but not limited to, any changes of address or name.
Revised 5/13/16 by MVCC
Page3
FIRE HAWK APPLICATION
VOLUNTEER SERVICE AGREEMENT - SPONSORING AGENCY
APPLICANT NAME:
APPLICANT D.O.B:
SPONSORING AGENCY:
Fire Dept/Co #:
FIRE CHIEF NAME (Print):
COURSE OF STUDY: ______________________________________
Full Time
Part Time
INSTRUCTIONS: To be filled out once at time of application.
Volunteer is to fill out the top portion of this form.
Fire Chief is to initial each statement below. Sign and date this form.
As a Sponsoring Agency, we commit to provide the following to the Fire Hawk Volunteer and,
when applicable, to the Advisory Board:
Initial next to each statement below.
_______ Confirmation that the candidate has met all local requirements for acceptance into the membership of the Sponsoring
Agency.
_______ A clear explanation of the Sponsoring Agency’s requirements that the candidate must fulfill prior to, during, and
following their course of study.
_______ A copy of Sponsoring Agency by-laws, standard operating procedures, or other duties and requirements.
Proper personal protection equipment.
_______ Qualified training commensurate with agency, local, county, state, and national standards.
_______ The Sponsoring Agency Verification and Tracking Form submitted on a semester basis to the Fire Hawk Advisory
Board, indicating whether the Fire Hawk Volunteer is providing the Sponsoring Agency with an appropriate and
acceptable level of volunteer service.
_______ Opportunities for development, advancement in rank, varied experiences, and further training.
Fire Chief Signature_____________________ Date____________
CHIEF – Please check one below:
_____New Recruit – a member of no more than six (6) months in good standing of a volunteer fire
department/company.
______Active Firefighter – actively involved in fire department/company of more than six (6) months in good
standing; trained to perform the function of fire prevention and suppression, and performs to their own
department’s minimum standards.
Revised 5/13/16 by MVCC
Page4
FIRE HAWK APPLICATION
VOLUNTEER SERVICE AGREEMENT - VOLUNTEER
APPLICANT NAME:
APPLICANT D.O.B:
Fire Dept/Co #:
FIRE CHIEF NAME (Print):
COURSE OF STUDY:
Full Time
Part Time
INSTRUCTIONS: To be filled out once at time of application. Volunteer is to fill out this page in its entirety.
Initial each statement below.
Sign and date this form.
As a Fire Hawk
Volunteer for the sponsoring agency, I agree to the following:
Initial next to each statement below.
_______ I agree to apply for all available sources of financial aid via the standard FAFSA (Free Application for Federal Student Aid) form and
will use Fire Hawk funds only to supplement any costs not covered by other sources of financial aid, grants and/or scholarships. Note:
Tuition and fees will be covered up to $5000 annually. Books and supplies are not included.
_______ I agree to fulfill the Sponsoring Agency’s volunteer activity and training requirements prior to, during, and following my course of study
through the end of my service obligation.
_______ I agree to a volunteer service term of three years from the date of the start of the scholarship.
_______ I understand and agree that MVCC, the Fire Hawk Advisory Board, and other Oneida County offices, divisions, or departments will
share my academic, financial, and volunteer firefighter service records and information in the necessary facilitation of such information
to determine my initial and continued eligibility for scholarship assistance throughout all relative enrollment within the Fire Hawk
program and as long as I am enrolled in courses at MVCC.
_______ I agree to reimburse Oneida County for any and all funds received under the Fire Hawk program in the event that I do not fulfill my
volunteer service commitment and/or maintain academic standards as established in the Fire Hawk Scholarship Recipient’s Guide and
as covered in the MVCC catalog. I understand that Oneida County shall have the right to employ a collection agency and/or any other
legal means to collect this debt, and assess against me all expenses incurred, including, without limitation, reasonable attorney’s fees.
_______ I understand that this scholarship is subject to availability of Oneida County funding.
__________
____________ ______________
Fire Hawk Volunteer Signature Date
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Revised 5/13/16 by MVCC
Page5
FIRE HAWK APPLICATION
SPONSORING
AGE
NCY VERIFICATION &
TRACKING FORM
APPLICANT NAME:
APPLICANT D.O.B:
SPONSORING AGENCY:
Fire Dept/Co #:
FIRE CHIEF NAME (Print):
INSTRUCTIONS: Each semester, the Fire Hawk student is responsible for having the Fire Chief fill out this form in its entirety and returning it
prior to the start of the semester to the address below.
In accordance with the requirements for the completion of the Fire Hawk Scholarship Program, I affirm that
_________________________ has met all service requirements to maintain eligibility and is performing to the department’s
minimum standards.
a new recruit
an active firefighter
Notes:
terminated service on:
Date________________________
Print name of Sponsoring Agency ________________________ in the municipality/ of __________________
___________________________________________________________________________________
Fire Chief Signature Date
Please return this form to Kevin Siembab, Mohawk Valley Community College, Career
Services, Alumni College Center, Room 102, 1101 Sherman Drive, Utica, NY 13501
FOR OFFICE USE ONLY
Check Appropriate Semester:
Fall
Spring
Summer
Comments
YEAR: _________________________
Verified by:
Date:
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Revised 5/13/16 by MVCC
Page6
FIRE HAWK APPLICATION
CERTIFICATION OF INFORMATION
By signing below, I hereby certify that the information supplied in this application is true to the best of my knowledge. I further
understand that the credentials filed in support of this application will become the final property of MVCC and/or also that of any
applicable office, division, or department of Oneida County.
FERPA—Release of Academic and Financial Records
I hereby understand and agree that it will be necessary for MVCC, the Fire Hawk Advisory Board, my sponsoring agency, and possibly
other Oneida County offices (as indicated above), to share various records and personal information of mine in order to determine my
initial and continued eligibility for scholarship assistance as relative to my application to and enrollment in the Fire Hawk program.
I acknowledge that such information and records may include, but not necessarily be limited to:
• Education and/or academic records, such as transcripts, grades and attendance
• Financial information (financial aid information and/or determination)
• Other protected personal information (as defined by FERPA*)
• Volunteer firefighter service records
By signing below, I hereby provide my permission for any and all pertinent information and/or records to be released and/or
s
hared accordingly.
Signa
ture: ______________________________________ Date:_________________
Name: __________________________________________ D.O.B.________________
Please print name
*MVCC is subject to the provisions of and complies with the Family Education Rights and Privacy Act of 1974 (“FERPA”). A statement of the college policy can be
found in the student handbook and college catalog. FERPA defines an “educational record” as “those records, files, documents, and other materials” that (1) “contain
information directly related to a student;” and (2) “are maintained by an educational agency or institution or by a person acting for such agency or institution
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Revised 5/13/16 by MVCC
Page7
FIRE HAWK APPLICATION
LETTER OF REFERENCE FORM
G
ENERAL
• At least one (1) letter of reference must be submitted to apply for the Fire Hawk program.
• Up
to three (3) letters of reference may be submitted.
S
ELECTING AN APPROPRIATE REFERENCE
• All applicants may submit a reference from an employer, work colleague, teachers or any other non-family member.
• Letters from family members are not acceptable.
• Individuals providing letters of reference must be familiar with your character and abilities.
S
UBMITTING THIS FORM
• The applicant should complete Section I of this form.
•
This form, with Section I completed, and a self-addressed stamped envelope, should be given to the person who has agreed to
provide a letter of reference (“the recommender”).
•
The recommender should complete Section II of this form and send it in the self addressed stamped envelop, sealed, and
signed over the seal, back to the applicant.
•
The applicant should include this letter of reference (in its unopened, sealed, and signed envelope) with his/her application
materials.
SECTION I: TO BE COMPLETED BY THE APPLICANT
Name:
Last _________________
First_________________________
Middle ____________
D.O.B
Month _______________
Day __________________________
Year ____________
RIGHT OF ACCESS WAIVER
Fire Hawk program participants have access to the information in their files as maintained by MVCC and Oneida County.
However, many recommenders choose not to provide letters of reference unless the confidentiality of those letters is ensured.
Therefore, as provided for under the Family Educational and Privacy Act of 1974, the Fire Hawk program requests that the
applicant complete the section below, indicating whether or not s/he waives his/her right to review this letter of reference. All
letters of reference will be given equal consideration by the Fire Hawk Advisory Board, without regard to the applicant’s decision
as indicated below.
I do waive my right of access to this letter of reference. This letter is strictly confidential.
I do not waive my right of access to this letter of reference. This letter is not confidential.
Applicant’s Signature: ____________________ Date:__________
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Revised 5/13/16 by MVCC
Page8
FIRE HAWK APPLICATION
LETTER OF REFERENCE FORM (page 2)
SECTION II: TO BE COMPLETED BY THE RECOMMENDER
Please print.
Applicant Name: _______________________________________________________________________
Recommender Name: _______________________________
Phone (W): ________________
Address: __________________________________________
Phone (H): _________________
Email: ________________________________________________________________________________
Position/Title: _________________________________________________________________________
Organization: _________________________________________________________________________
Relationship to Applicant: ______________________________________________________________
How long have you known this applicant? _________________________________________________
Complete the following table. Indicate your ratings with an “X” in the appropriate boxes.
Excellent
Very Good
Good
Fair
Poor
Ability to handle stress
Responsibility and Accountability
Reliability
Time Management
Attendance Record
Include a brief description of (1) this applicant’s strengths and weaknesses, and (2) why you are or
are not recommending this applicant for the Fire Hawk program.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
(Continue on the back of this form or attach an additional sheet of paper)
Check the level at which you recommend this applicant for the Fire Hawk program.
_______Strongly recommend
_______Recommend
_______Recommend with reservations
_______Do not recommend
Recommender’s Signature: _________________________
Date: ________________
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Completed 26 July 2020

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