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2. **NOTE: You must be 18 years of age or older to use this online registration form.**

   Individuals under the age of 18 must download and submit a traditional registration form (parent/guardian signature required).

4. Fire Company Name*
5. County*
6. Station #*
8. Student Name
10. First*
11. Middle Initial
12. Last Name*
14. Student ID*

    First three letters of last name & last four digits of social security number

15. Date of Birth*
    Date of Birth
16. Rank*
    -- Select One --FirefighterLieutenantCaptainBattalion ChiefAssistant ChiefDeputy ChiefChiefFire PoliceFire Police CaptainOther
18. FEMA SID*
19. Register for a FEMA SID:
    https://cdp.dhs.gov/FEMASID/register
20. Date Joined Fire Company/Dept*
    Date Joined Fire Company/Dept
22. Course Name/Start Date*
    -- Select One --Advanced Fire Police - 10/21Advanced Line Systems Rescue - 9/21Aerial Apparatus Operations - 9/30Arson Awareness (online) - 9/28Arson Detection for the First Responder - 11/4Chimney Fire & Heating Related Emergencies (online) - 10/23Emergency Vehicle Operator Training - 9/23Emergency Vehicle Operator Training - 10/30Engine Company Operations - 10/21Fire Ground Support - 9/28Fire Instructor - 11/5Fire Officer I - 9/23Foam Firefighting Basic - 11/18HazMat Operations Certification Prep - 10/14HazMat Operations Refresher - 10/22HazMat Operations Refresher (online) - 12/5Hoarding - Emergency Response Perspective (online) - 11/20Interior Fire Fighter - 10/15NFPA 1670 Vehicle Rescue Awareness - 9/27NFPA 1670 Vehicle Rescue Awareness - 10/30NFPA 1670 Vehicle Rescue Operations - 10/19NFPA 1670 Vehicle Rescue Operations - 11/29Pump Operations I - 9/25Pump Operations II - 10/2Rapid Intervention Teams (online) - 11/13Rescue Technician - Vehicle Level I - 10/3Response to Chemical Suicide (online) - 11/6Structural Collapse Operations Level I - 10/11Structural Collapse Operations Level II - 10/14Trench Rescue Awareness - 11/15Trench Rescue Operations - 11/18Truck Company Operations II - 10/10Water Rescue Night Operations - 10/24
23. Make-up?

    1. Check for a make-up class
25. Email Address*
26. Phone Number*
28. Home Address*
29. New address, email, or phone*

    1. Yes
    2. No
31. Name of Authorizing Officer*
32. Title*
33. Email Address of Officer*
35. Name of Training Officer*
36. Title*
37. Email Address of Officer*

39. I grant to Montgomery County Fire Academy, the right to take photographs of me in connection with the above-identified event.  I authorize Montgomery County Fire Academy, its assignees and transferees to copyright, use and publish the same in print and/or electronically.

    I agree that Montgomery County Fire Academy may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

41. Acknowledgement*

    1. I have read and understand the above.
42. Student Initials*

44. I voluntarily assume all risk of loss, damage, illness or injury that I may sustain while participating as a student in Montgomery County Fire Academy activities.

    I release the County of Montgomery and its officers, agents, and employees from any and all claims, demands, and causes of action on account of any injury or loss which may occur during my participation in Montgomery County Fire Academy activities, through negligence, omission, default or other action of any person or organization associated with such activities.

    Individual Insurance: The County of Montgomery is not authorized to provide travel, medical, or Health insurance for students. You are advised to obtain appropriate insurance on an individual basis. If you are presently insured you should check your policy to assure yourself of sufficient and appropriate coverage.

46. Acknowledgement*

    1. I have read and understand the above.
47. Student Initials*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field