MASSACHUSETTS STATE 911 DEPARTMENT
MODULE TRAINING - Application for Enrollment
Course Information (Please fill in the course or courses you would like to attend, one application per person)
COURSE TITLE DATE TIME LOCATION
* PLEASE MAKE NOTE OF PREREQUISITES – Proof of certification is REQUIRED or your
application will be denied!
Section 1 – Student Information
Last Name __________________________ First Name _________________________ Middle Initial _________
Full Address _____________________________________ E-Mail Address _____________________________
Phone Number ___________________________________ Position Title ______________________________
Date of Birth _____________________________________ Date of Hire/Appointment ____________________
Last Four Digits of SS#_____________________________ Status of Employment (Full or Part-Time) ________
I, ______________________________,
agree to comply with all guidelines set forth by the Massachusetts State
Printed Name of Applicant
911 Department with regard to its training programs and understand that I may be subject to dismissal from the program for infractions thereof. I also
agree that in case of accident or illness, the training staff may take whatever actions are deemed necessary to arrange for emergency medical services. In
the case of injury or illness resulting from training, all necessary medical expenses will be borne by the sponsoring agency. I agree that all issues of civil
liability shall be determined in accordance with Chapter 258 of the Massachusetts General Laws.
Signed: ______________________________ Rank or Title: _________________________ Date: _____________
Section 2 – Agency Information
Name of Agency ________________________________ Full Address _______________________________
Phone Number ________________________________ Fax Number _______________________________
Supervisor ________________________________ Supervisor’s Title ___________________________
Type of Agency (Police, Fire, EMS or Combination) _________________________________________________
EMD is: provided In-house CPR certified What EMDPRS is your PSAP using? _______________________________
Provided by (Certified EMD Resource): _____________________________
I, _____________________________,
approve this applicant for attendance at the above named academy session and
Printed Name of Chief Officer
further agree as the chief executive officer of the sponsoring agency to abide by the training guidelines as established by the Massachusetts State 911
Department, and understand that the program may include various types of training. I stipulate that the applicant will be employed by the sponsoring
agency during periods of participation
in the training program, and that the sponsoring agency assumes responsibility for all necessary medical expenses
for injury or illness resulting from training. I agree, as the chief executive officer of the sponsoring agency, that the applicant shall be covered by
emergency health care insurance during his/her participation in the training program activities, and also agree that in the case of illness or injury the
training staff may take whatever actions are deemed necessary to arrange for emergency medical services. I agree that all issues of civil liability shall be
determined in accordance with Chapter 258 of the Massachusetts General Laws.
Signed: ______________________________ Rank or Title: _________________________ Date: _____________
Please note, a student has not been approved for attendance at a class until a confirmation has been received via fax from the State 911 Department Training Division
