FIRE SERVICE WOMEN OF NEW YORK STATE TRAINING CONFERENCE by RodneySooialo

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									                           FIRE SERVICE WOMEN OF NEW YORK STATE
                         TRAINING CONFERENCE - SEPTEMBER 16-21, 2008
                                            New York State Academy of Fire Science
                                        600 College Ave., Montour Falls, NY 14865-9634
                                              (607) 535-7136; Fax: (607) 535-4841


                     Personal Information                                        Fire Department Information
NAME (Last, First, MI)                                            FIRE DEPARTMENT ID #                                 COUNTY


STUDENT ID NUMBER                                                 SPONSORING ORGANIZATION


HOME ADDRESS (Street, PO Box)                                     STREET ADDRESS, PO BOX


CITY                       STATE           ZIP                    CITY                           STATE                 ZIP


                                                                  FD PHONE#                                 FD E-MAIL or FAX
  CHECK IF NEW ADDRESS
DAYTIME PHONE                      EVENING PHONE

                                                                                   OFPC CREDIT COURSES
E-MAIL ADDRESS
                                                                      See class schedule for exact dates, times & prerequisites
                                                                                      Circle your class choices below
                                                                  Course
                                                                                                                                          Fee
                                                                    9/16-17
SHARE ROOM WITH:__________________________                            Firefighter Survival - 12 hrs.                                    $25.00
                                                                    9/16-18
                                                                      Fire Officer I - 24 hrs.                                          $25.00
 SEE REVERSE SIDE FOR WHAT THE FEES COVER                             Rescue Technician Basic - 24 hrs.                                 $25.00
                                                                    9/17-18
    $25.00 REGISTRATION FEE FOR ALL ATTENDEES                         *SCBA Confidence - 12 hrs.                                        $25.00
       EACH ADDITIONAL CREDIT COURSE REQUIRES                       9/18-19
       A $25.00 REGISTRATION FEE
                                                                      *SCBA Confidence - 12 hrs.                                        $25.00
                                                                      Water Rescue Operations - 16 hrs.                                 $25.00
Meals/Lodging - $40.00 Per Day (Includes Dinner)                      Highway Safety for Emergency Responders - 16 hrs.                 $25.00
                                                                    9/19
    Monday - Saturday 9/15 - 9/20 - $240.00
                                                                      School Bus Rescue - 4 hrs.                                        $25.00
                                                                      School Bus Practical Skills - 4 hrs.                              $25.00
    Tuesday - Saturday 9/16 - 9/20 - $200.00                          AWR 140: Radiation Course 6 hrs.
                                                                      Domestic Preparedness Response-to Radiation Incidents - 4 hrs.    $25.00
                                                                    9/20
    Wednesday - Saturday 9/17 - 9/20 - $160.00                        Decontamination - 4 hrs.                                          $25.00
                                                                      Alternative Fueled Vehicles and New Technology - 4 hrs            $25.00
    Thursday - Saturday 9/18 - 9/20 - $120.00                       9/21
                                                                      Courage to be Safe - 4 hrs.                                       $25.00
    Friday - Saturday 9/19 - 9/20 - $80.00                            Water Rescue Awareness - 4 hrs.                                   $25.00
                                                                      Decon Trailer Equipment Training - 4 hrs.                         $25.00
Please note that Check-Out time is Sunday at 8:00a.m.               *Please note that two SCBA Confidence courses are being offerered separately.
                                                                      __________ TOTAL COURSE FEES
                                                                      __________ TOTAL DUE (Lodging & Meals + Fees )
                                                          Payment Method
        Checks, money orders & vouchers are payable to:             VISA           MasterCard         Total Charge: $______________
                 NYS Academy of Fire Science                      Card Number: _______________________________________
             Check                              Voucher           Expiration Date_________FAX CREDIT CARD REGISTRATIONS
             Money Order                        Other (specify)   Signature____________________________________

                            This form is on the web at http://www.dos.state.ny.us/fire/pdfs/women.pdf
                                  MAIL OR FAX APPLICATION TO FIRE ACADEMY ONLY
    APPLICATION DEADLINE SEPT. 2. This is a 2-page application. Both pages must be completed.
                                                                                                                                            7.
                                                         APPLICATION - PAGE 2
                                              APPLICATION DEADLINE SEPT. 2.




     Please note that Check-Out time is Sunday at 8:00a.m.
    $40.00 a day times number of days staying + registration fee and any credit course fees

    COMMUTERS ENTER THE NUMBER OF MEALS YOU WOULD LIKE
    ALL COMMUTERS PLEASE CHECK REGISTRATION FEE ON FRONT OF APPLICATION ($25.00)


    _____ $4.00 BREAKFAST

    _____ $4.00 LUNCH

    _____ $9.00 DINNER




                                                                            --
                                                                    Model Consent
I CONSENT to the use of my name and/or likeness for the purpose of advertising or trade by the New York State Department of State, or anyone
authorized by that Department to act on its behalf. “My likeness” includes a photograph, video tape recording, film or artistic rendering of me, a
recording of me, a recording of my voice and/or reproductions of any of these. I agree that the actual material involved, such as a photograph, neg-
ative, plate, video tape recording, film or audio recording is and shall continue to be the property of New York State Department of State. I under-
stand and agree that I will not be compensated in any way for the use of my name and/or likeness and that I am free from any responsibility for
these expenses. If more than one person signs this consent, each person hereby agrees to the preceding provisions.
IF THE PERSON WHO IS BEING PHOTOGRAPHED, FILMED, VIDEO TAPED OR RECORDED IS UNDER AGE 18, HIS/HER PARENT OR GUARDIAN MUST SIGN
BELOW INSTEAD.


Signed: __________________________________________Date: _________________________

Address: ______________________________________________________________________

Description: Fire Service Women of New York State 7th Annual Training Weekend - 2008

Witness:_________________________________________________________ DOS-895 (Rev. 3/96)

    Consent is denied. ________Date______________________




                                                                                                                                                8.

								
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