Less Than 10 Seconds

"Less Than Ten Seconds" - My Near Miss Story

Presented by the Lakes Region Mutual Fire Aid Association Training Division
Personal Information
Name*

First NameLast NameSuffix
Home Mailing Address*

Street Address (or PO Box)

Street Address Line 2

CityState

Zip Code
Day Phone*
Please enter a valid phone number.
Night Phone
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Email*
example@example.com
Agency Information
Department / Agency Name*
Position / Rank*
Agency Mailing Address*

Mailing Address

Mailing Address Line 2

CityState

Zip Code
Agency Phone*
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Please read and acknowledge the following

I certify that the information recorded on this application is correct. I agree to abide by the rules, policies, and regulations Lakes Region Mutual Fire Aid Association if I am admitted as a student. Falsification of information may result in a denial of a course certificate. I hereby authorize release of any and all information concerning my enrollment in this course to the chief officer in charge or designee of my organization. All requests for information shall be in written form from said chief or designee.

I certify that the listed applicant is a member of the listed fire department/agency and is covered by Worker’s Compensation Insurance. Non-affiliated students shall provide proof of insurance.

I further certify that the listed applicant meets or exceeds prerequisites for this program, if applicable.
I agree to comply with the above statements
Enter full name to electronically sign this form*
By signing this form you affirm that you will either pay directly by cash, check, or money order; or you have authorization from the listed agency to authorize billing.
Date*

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"Less Than Ten Seconds" - My Near Miss Story