Sussex County Fire Academy 114 Morris Turnpike 973-948-7897 Newton NJ 07860 FAX 973-948-7898 Training/Facilities Application Course Requested _______________________________ Department ________________________________ Address For Confirmation _____________________________________________________________________ (Zip) Chief's Name _________________________________________ Daytime Phone ________________________ Dept. Training Officer's Name ___________________________ Daytime Phone ________________________ Dept. Safety Officer's Name _____________________________ Daytime Phone ________________________ Date Preferred - If more than one date is offered, please give an alternate choice ____________________________________________________________________________________________________ PLEASE MAIL APPLICATION OR FAX TO FIRE ACADEMY AT (973) 948-7898 Enrollment Eligibility Only those applicants meeting pre-requisites will be accepted. Outdoor Programs (Practical Exercises)..........Turnout gear requirements will be given with confirmation. Indoor Programs (Lectures).............................Be prepared to take notes and receive handouts. Class Hours - Unless Otherwise Stated Evening Classes – 7:30 PM - 10:30 PM Saturday Classes – 8:30 AM - 4:30 PM It is understood that any and all responsibility for personnel injury to any member(s) of the applying department shall rest upon the municipality in which the member(s) of the applying department normally perform their duties, said department members being active members assigned to the Fire Academy, Fire Training Center or satellite location. This responsibility includes compliance with NJ PEOSHA regulations pertaining to firefighters. Certification: I hereby certify that all personnel from this department enrolled in the above course are covered by workmen's compensation and liability insurance or otherwise adequately insured. Date________________________ ________________________________________________________ Chief or Authorized Signature Sussex County Fire Academy 114 Morris Turnpike 973-948-7897 Newton NJ 07860 FAX 973-948-7897 Members Enrolling for Training Upon entering the premises of the Fire Academy for the purpose of training, the members listed below release the Fire Academy of Sussex County and its instructors of any responsibility on their part, in case of accident: Please Print Clearly Or Type Date ____________________ Course __________________________ Dept _________________________ Course Start Date ______________ Name/Rank Social Security No. Phone No. 1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. __________________________________________________________________________________________ 6. __________________________________________________________________________________________ 7. __________________________________________________________________________________________ 8. __________________________________________________________________________________________ 9. __________________________________________________________________________________________ 10. __________________________________________________________________________________________ 11. __________________________________________________________________________________________ 12. __________________________________________________________________________________________ 13. __________________________________________________________________________________________ 14. __________________________________________________________________________________________ 15. __________________________________________________________________________________________
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