Clone of 2.26 EMR Registration

1
First Name* This field is required.
2
Last Name* This field is required.
3
Social Security Number* This field is required.Must provide - Necessary for state certification
4
Date of Birth* This field is required.Must provide - Necessary for state certification
Date
Month
Day
Year
5
Certification NumberPlease provide if you already hold State of Ohio Certification
6
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
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Maine
Maryland
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Michigan
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Mississippi
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New Hampshire
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
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Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
County* This field is required.Please list the county you reside in
County
8
Phone Number* This field is required.
Area Code
Phone Number
9
Email* This field is required.
example@example.com
10
Course billed to?* This field is required.
SELFDEPARTMENT
11
Department NamePlease list department if you are currently affiliated. *This question is required even if it is self pay.
12
Department Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Fire ChiefPlease list Fire Chief or his designee for point of contact
14
Department Phone Number
Area Code
Phone Number
15
Department Email* This field is required.
example@example.com
16
Have you met the pre-requisites?If completed please mark and attach.
NIMS 100
NIMS 700
Rescue Task Force Training
Ohio Trauma Triage Course
BWC / Insurance Verification (Letter from chief verifying BWC coverage is acceptable)
17
NIMS 100Please provide date of completion for NIMS 100
Date
Year
Month
Day
18
NIMS 700Please provide date of completion for NIMS 700
Date
Year
Month
Day
19
Pre-requisites Please provide copies of prerequisites if available. If not available, please bring to first class. *PDF’s preferred
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Signature* This field is required. The Wellston Fire Department Training Academy (herein “ACADEMY”) and its partner agencies, in making available their or other selected facilities, training grounds, equipment, and its staff, and in its provision of an opportunity to learn on the part of its students and other invitees, makes no representation of and assumes no liability for the suitability or condition of its or other selected facilities, training grounds or equipment, or for the competency of its staff, or for the quality and content of its educational services. The ACADEMY assumes no liability for and shall be indemnified and held harmless for any claims, demands or suits of any nature, kind or description whatsoever, including, but not limited to claims for direct, indirect or consequential damages, acts of god, or any types costs and expenses, for or on account of any loss or damage to property owned or possessed by any student or other invitee or any injury to any student or invitee which may result from any cause, including but not limited to, the condition and operation of ACADEMY facilities, training grounds, and equipment, or the condition and operations of any other selected facilities, training grounds and equipment, and the acts or omissions of members of its staff or the acts or missions of other students or invitees. The members of the Wellston Fire Department Training Academy staff and the instructors, in their personal and representative capacity, assume no liability for and shall be indemnified and held harmless for any claims, demands or suits of any nature, kind or description whatsoever, including, but not limited to claims for direct, indirect or consequential damages, acts of god, or any types costs and expenses, for or on account of any loss or damage to property owned or possessed by any student or other invitee or any injury to any student or invitee which may result from any cause, including but not limited to, the condition and operation of ACADEMY facilities, training grounds, and equipment, or the condition and operation of any other selected facilities, training grounds and equipment, and the acts or omissions of members of its staff or the acts or omissions of other students or invitees. Student or invitee hereby authorizes the ACADEMY to seek emergency medical assistance on his or her behalf, as necessary, and agrees to pay for any and all medical expenses incurred on his or her behalf, Student or invitee shall indemnify and hold harmless the ACADEMY for any and all such emergency medical expenses and for any claims related to the aid rendered to the student or invitee by the Academy or its Staff during any such emergency situation. By signing this document, the student or invitee hereby voluntarily acknowledges that he or she understands and accepts the above terms as a condition of the student or invitee’s participation in any Academy sponsored event, training, class, use of any Academy property or equipment or other circumstance as described in paragraph one of this waiver and that any such participation in the aforementioned activities may involve difficult, strenuous and dangerous physical activities to be undertaken by the student or invitee and that the student or invitee expressly assumes all of the risks associated with such activities. The student or invitee further expressly agrees not to bring a suit for damages against the City of Wellston, its employees or any independent contractors based upon any of student or invitees liabilities they waived in this document. This document constitutes the complete agreement between the parties.
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