MASSACHUSETTS STATE 911 DEPARTMENT
PSCA - PUBLIC SAFETY COMMUNICATIONS ACADEMY
Application for Enrollment
Academy Information
Academy Start Date: _____________________________
Orientation: _____________________________
*Attendance is mandatory*
Class Times: Monday – Friday 8:30 am – 4:30 pm. (unless otherwise noted)
Location: _____________________________
Section 1 – Student Information
Last Name __________________________ First Name _________________________ Middle Initial _________
Full Address _____________________________________ E-Mail Address _____________________________
Phone Number ___________________________________ Other Number ______________________________
Date of Birth _____________________________________ SS Number ________________________________
Date of Hire/Appointment __________________________ Status of Employment (Full or Part-Time) ________
I, ______________________________,
agree to comply with all rules and regulations set forth by the Massachusetts
Printed Name of Applicant
State 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 ___________________________
Agency Type: Police Fire EMS 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 regulations 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 SETB Training Division
