Louisiana Firefighters Foundation
Firefighter/EMR/EMT/AEMT Application - Step 1
Applicant Information:
Class Applying For:
*
Firefighter ($2400)
EMR ($450)
EMT ($2000)
EMT with AEMT Bridge Add-on ($2000 +$400)
AEMT ($2000)
Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drivers License : State and #
*
LA 123456
DL Expiration:
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-
Month
-
Day
Year
Date
Current Employer:
How did you hear about us?
*
Social Media, Friend, LFF Member, If other please be specific
Shirt Size:
*
Please Select
X-Small
Small
Medium
Large
X - Large
XX - Large
XXX - Large
(Fire Academy Only) Pant Size: Waist, Length [ex. 32, 34]
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Emergency Contact
Emergency Contact Person:
*
First Name
Last Name
Relationship to Applicant:
*
Emergency Contact Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Number:
*
Please enter a valid phone number.
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Certification Information
CPR Course Provider
Please Select
American Red Cross
American Heart Association
No Current CPR Certification
Other
CPR Expiration Date:
NREMT #: (only if AEMT applicant)
State EMT License #: (only if AEMT applicant)
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Medical History
Have you ever had any of the following?
*
Yes
No
Heart/Cardiac Problems
Seizures
Lung/Asthma/COPD
Arthritis
Hypertension
Heat Stress
Injury to Joints (shoulder, hip, knee, etc)
Anxiety
Surgery within last 3 years
Vision (glasses, contacts, etc.)
Injury to back, neck or spine
Learning Disability
Emotional Distress
Do you have a physical condition that requires accommodation?
If you answered yes to any of the questions, please explain.
Medical History Continued...
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Yes
No
Do you have any medical/physical condition that may restrict you mentally/physically?
In confined spaces?
In stressful situations?
In extreme climates?
Heights or water?
Allergies?
If you answered yes to any of the questions, please explain.
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Agreements
Are you willing to take a drug and/or alcohol test?
*
Yes
No
Have you ever been arrested? Please select "Yes" even if the charges were dropped or expunged.
*
Yes
No
I understand the use of illegal drugs, controlled substances and/or alcohol is prohibited on or in all Academy grounds, vehicles, equipment, and property. I also understand that if I am found under the influence of illegal drugs, controlled substances, and/or alcohol while on or in all Academy grounds, vehicles, equipment, and property, I will be expelled immediately.
*
I agree to these terms
I do not agree to these terms
I will consider my safety and the safety of my fellow students and instructors above all else. I will perform my duties to the best of my ability. I understand that my activities outside of the Academy directly reflect on the school and I will act accordingly.
*
I agree to these terms
I do not agree to these terms
I understand that any Academy property issued to me must be returned at the time of my course completion or whenever it is requested by my instructors. Failure to do so will result in legal action and/or paying for the replacement of such property.
*
I agree to these terms
I do not agree to these terms
I grant the Louisiana Firefighters Foundation Academy, its representatives and employees, the right to take photos, videos, or audio recordings of me and my property in connection with the Academy's Courses. I authorize the Louisiana Firefighters Foundation its assigns and transferee to copyright, use, and publish the same in print and/or electronically. I agree that the Louisiana Firefighters Foundation 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.
*
I agree to these terms
I do not agree to these terms
Only for EMT/AEMT - Personnel completing clinical shifts at either an EMS Transport Agency or Healthcare Facility must show Proof of Vaccinations or obtain a qualified exemption.
I will provide proof of vaccinations
I am not completing EMT/AEMT/EMR training and therefore do not need Proof of Vaccination
I chose to decline/refuse vaccinations and will be completing a Vaccination Waiver.
I have read and understand the above terms and conditions:
Your signature below acknowledges your acceptance of these terms and conditions.
Signature
Today's Date:
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
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