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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