Fillable Form 1: Bucks County Community College Department of (Bucks County Community College)

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Form 1: Bucks County Community College Department of (Bucks County Community College)

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Bucks County Community College
Department of Public Safety Training and Certification
Student Enrollment Form
1760 South Easton Road
Doylestown, PA 18901
Ph: 215.340.8417
Fax: 215.343.6794
www.bucks.edu/publicsafety
1
SOCIAL SECURITY NUMBER
DATE OF BIRTH
BCCC STUDENT NUMBER
GENDER
Female
TITLE
COUNTY OF RESIDENCE (PA Residents Only)
Male
Mr.
Ms.
Mrs.
Miss
SUFFIX
FIRST NAME
MI
2
ADDRESS (Street Address or Postal Box Address)
APT#/UNIT#
CITY
STATE
ZIP CODE
For International Addresses please use the open line below for City, State or Providence, Postal Codes and Country.
3
CELL (Mobile) Phone No.
HOME (night-time) PHONE NO.
WORK (day-time) PHONE NO.
E-MAIL ADDRESS:
4
ORGANIZATION/EMPLOYER (Agency you are representing during the course)
ORGANIZATION/EMPLOYER PH. NO.
ADDRESS (Street Address or Postal Box Address)
CITY
STATE
ZIP CODE
5
METHODS OF PAYMENT: Select invoice options Section 5A and select method of payment Section 5B
5A.
Invoice the student
5B.
Personal Check (#__________)
VISA or MasterCard: A completed
Credit Card Authorization Form must be
submitted, Form available on our website.
Invoice the Organization/Employer
Organization Check (#_________)
Bucks & TMP (Silver/Gold)
Organization P.O. (#__________)
6
COURSE NUMBER & SECTION
COURSE TITLE
START DATE
HOURS
COURSE LOCATION: COUNTY:
7
AUTHORIZATION
A.
Meets the qualifications and age requirements to attend including all of the necessary prerequisites. Copies of certificates must be brought to first day of class.
B.
Is covered by his/her company’s WORKERS’ COMPENSATION INSURANCE, or is covered by his/her own Health and Medical Insurance while attending
any course sponsored by the Bucks County Community College.
C.
Will abide by all the rules and regulations established by the Bucks County Community College and the Pennsylvania State Fire Academy.
D.
Will abide by 29 CFR 1910.134 and the Pennsylvania State Fire Academy for being clean-shaven for classes requiring the use of APR or SCBA.
E.
Has no knowledge of conditions that will prohibit full participation in all activities required for successful completion of the class.
F.
Will be responsible to pay for any tuition and/or fees associated with the course, unless otherwise notified by the sponsoring Organization/Employer that is listed
in Section above. (See section 5 for information on who should be invoiced and the payment method)
G.
Junior Fire Fighters (ages 16-17) will abide by all regulations under the Pennsylvania Child Labor Laws and will not register for or participate in any class with
drills involving live fire or smoke generated by live fire.
H.
The candidate should meet the requirements of NFPA 1582, Standard on Medical Requirements for Fire Fighters and Information for Fire Department
Physicians, within a reasonable period of ti
me prior to entering into physical training or testing to ensure his or her ability to safely perform the required tasks.
(See back of this page for further detail of the 13 essential job tasks and descriptions.)
I.
I, the Student have never been convicted of an offense that constitutes the crime of “arson and related offenses” under 18 Pa.C.S §3301 or any similar offense
under any Federal or state law. I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand
that if I knowingly make any false statement herein, I am subject to penalties prescribed by law, including, but not limited to, a fine of at least $1,000.
By signing this form below you, the student, agree to the first nine items (A thru I) listed above. Registrations will not be processed without Signature of Student.
SIGNATURE OF STUDENT
DATE SIGNED
SIGNATURE OF CHIEF/SUPERVISOR
DATE SIGNED
Registrations will not be processed without Signature of Student on day of class, and Pre-registrations will not be processed without Signature of both Student and
Chief/Supervisor.
Last Revised on 02/25/2016
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Bucks County Community College
Department of Public Safety Training and Certification
Student Enrollment Form
1760 South Easton Road
Doylestown, PA 18901
Ph: 215.340.8417
Fax: 215.343.6794
www.bucks.edu/publicsafety
Essential Job Tasks and Descriptions from NFPA 1582, 2013 edition
1) While wearing personal protective ensembles and self-contained breathing apparatus (SCBA), performing
firefighting tasks (e.g., hoseline 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 including working in extremely hot or cold environments for prolonged time
periods.
2) Wearing an SCBA, which includes a demand valve–type positive-pressure face piece or HEPA filter masks,
which requires the ability to tolerate increased respiratory workloads.
3) Exposure to toxic fumes, irritants, particulates, biological (infectious) and non-biological hazards, and/or heated
gases, despite the use of personal protective ensembles and SCBA.
4) Depending on the local jurisdiction, climbing six or more flights of stairs while wearing fire protective
ensemble, including SCBA, weighing at least 50 lbs (22.6 kg) or more and carrying equipment/tools weighing
an additional 20 to 40 lbs (9 to 18 kg).
5) Wearing fire protective ensemble, including SCBA, 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).
6) While wearing personal protective ensembles and SCBA, 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.
7) While wearing personal protective ensembles and SCBA, advancing water-filled hoselines up to 2 ½ in.
(65mm) in diameter from fire apparatus to occupancy [approximately 150 ft (50 m).], which can involve
negotiating multiple flights of stairs, ladders, and other obstacles.
8) While wearing personal protective ensembles and SCBA, climbing ladders, operating from heights, walking or
crawling in the dark along narrow and uneven surfaces that might be wet or icy, and operating in proximity to
electrical power lines or other hazards.
9) 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.
10) Operating fire apparatus or other vehicles in an emergency mode with emergency lights and sirens.
11) 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.
12) Ability to 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), hear alarm signals, hear and locate the source of calls for assistance from victims or other
firefighters.
13) 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.
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Form 1: Bucks County Community College Department of (Bucks County Community College)

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Completed 26 July 2020

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