VEHEXT 2021 Registration Form

VEHEXT 2021 Registration Form
VEHEXT is a three-day vehicle extrication course sponsored by the Charlottesville-Albearle Rescue Squad. It is a combination classroom and practicum class taught at the operations/technician level with technician level scenarios.

When: March 12-14, 2021

Where: The classroom portion and some of the practical stations will be held at the National Guard Armory in Charlottesville, VA. 165 Peregory Ln, Charlottesville, VA 22902. The rest of the class will be held at a local junkyard. Students will meet at the armory and will be shuttled to the junkyard (~10mins away). Class starts at 0800 each day and students should plan on each day concluding around 1700hrs.

Required PPE that you must bring to participate as a student: PPE according to your department SOP. However, the following will be acceptable: Structural PPE, Forestry type gear, USAR, extrication specific suits or cover-alls. The following are mandatory: helmet, gloves, and eye protections. Helmet face shields are NOT acceptable eye protection.

Pre-requisites: You must be 18 years or older to participate and have complete Haz-Mat awareness. A copy of your certificate must be uploaded with the application. Previous extrication experience is not required, but is a PLUS.

Lunch will be provided all three days as well as a light offering of snacks in the morning. Water will also be provided.

Cost: $200. Online payment is due at the time of registration.

Click Next to continue with the application.

Coronavirus Policies
The coronavirus pandemic has forced VEHEXT to adjust for the 2021 class. We are making these changes to keep both students and staff as safe as possible during this time.

We ask that all students and staff follow these policies in order to keep everyone as safe as possible.

The class changes have been developed based on the Virginia Department of Fire Program's Pandemic Operations policies (Found here).

VEHEXT 2021 Coronavirus classroom changes:
- All students and staff will fill out a daily symptom attestation prior to entering class facilities.
- All students and staff will have their temperature taken prior to entering class facilities.
  - If a student is experiencing symptoms or develops a fever, they will not be allowed to continue with the remainder of the class. No refunds will be issued.
- Masks MUST be worn at all times both inside and outside of buildings, including during training scenarios.
  - Mask will be provided to all students and staff for use during class.
- Students and staff will maintain social distancing (>6') whenever possible
- Meals will still be provided, but will be individually boxed lunches.
- Indoor student areas will be disinfected daily.
Since many students of this class may be involved in direct patient care of patients positive for SARS-CoV-2, high-risk exposures within 2 weeks of the class start must adhere to CDC guidelines for return-to-work (Found here). Please contact VEHEXT staff at vehext@rescue1.org for further guidance.

What is considered a high-risk exposure?
- Contact with COVID-19 positive person without adequate PPE (mask on provider and patient, N95 or higher if performing an aerosol-generating procedure)
If the state regulations on gathering size do not allow for >25 students, the class will be cancelled and refunds issued.
By signing here, you acknowledge you have read the above coronavirus policies and agree to follow them for the duration of the class: *

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Date *

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VEHEXT 2021 Registration

Student information
Please complete all fields of the registration form below.
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
example@example.com
Date of birth *

Month Day Year
Haz-Mat Awareness certificate *

Upload a File

Cancel of
Your Agency *
If you answered Other, please specify: *
How did you hear about the class *
If you answered Other, please specify: *
Your response to the following question will not prevent you from class participation. However, based on current literature, VEHEXT staff strongly suggest vaccination against the SARS-CoV-2 if you are able to receive it.
Have you been vaccinated against the SARS-CoV-2 *

Yes, both doses Yes, one dose No

Waiver and Release of Liability, Assumption of Risk and Indemnity Agreement

NOTICE:
● This is a legal instrument, has legal significance and affects your legal rights. Read and understand it before you sign.

● You are under no obligation to take this training class. However, if you choose to take this class, in return you must complete and sign this form.In consideration of permitting me to participate in recreational and /or technical rescue training and related training (collectively "Training") conducted by, sponsored by, or held on the property of, the Charlottesville- Albemarle Rescue Squad, Inc., (CARS), I, for myself, my personal representatives, heirs and assigns:

HEREBY ACKNOWLEDGE:

● that the activities involved in the Training are of a hazardous nature and contain inherent risks of serious injury and/or death and/or property damage and may be conducted at sites that are remote, either by time or distance or both, from medical facilities. The undersigned also expressly acknowledges that injuries received may be compounded or increased by negligent rescue operations or procedures of the Releasees and/or others.

● that it is entirely my responsibility to determine that I have and wear proper protective equipment, have proper physical and mental health, appropriate training and/or prior experience for each Training class. I alone am responsible for the suitability and condition of my personal protective equipment.

● that no insurance coverage is provided me by CARS or any other entity or person conducting the Training. It is my responsibility to arrange such coverage through my personal insurance or my agency prior to participating in the Training.

HEREBY REPRESENT that I have educated myself as to the Training requirements, and I a) have no physical or mental condition, nor b) am I taking any prescription or non-prescription medication that would preclude my participation in the Training.

HEREBY AGREE:

● for the duration of the Training to be free from the influence of alcohol and all drugs (prescription or non-prescription) that affect mental awareness or physical coordination or capability;

● to follow any rules provided me by members or officers of CARS and/or the Training instructors;

● that the Training instructors and/or officers of CARS may require me to leave the training program if they, in their sole discretion, believe that my actions, attitude or conduct are detracting from the safety or participation of themselves or other participants or compromisingother site users; and,

● that no Training instructor or officer of CARS is authorized to modify this instrument in any way.

THEREFORE, I HEREBY RELEASE, WAIVE, DISCHARGE (AND COVENANT NOT TO SUE) the Charlottesville – Albemarle Rescue Squad, Inc., and all of its officers, instructors, agents and members (all collectively the "Releasees") FROM ALL LIABILITY TO ME, my personal representatives, heirs, and assigns FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR ON ACCOUNT OF INJURY TO MY PERSON OR PROPERTY OR RESULTING IN MY DEATH, NOW AND FOREVER, ARISING OUT OF OR RELATED TO PARTICIPATION IN THIS TRAINING, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HEREBY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, now and forever, arising out of or related to participation in this training class, whether foreseen or unforeseen, known or unknown, and whether caused by the negligence of the Releasees or otherwise, I HEREBY SEPARATELY agree to INDEMNIFY and SAVE and HOLD HARMLESS the Releasees from any loss, liability, damage or cost they may incur, now and forever, arising out of or related to participation in the Training, whether caused by the negligence of the Releasees or otherwise, expressly including any claim by unforeseen third parties that techniques taught in this program caused or aggravated any property damage or personal injury because I applied the same in Training or an emergency response.

I HEREBY acknowledge that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES or others and agree that this Waiver and Release of Liability, Assumption of Risk and Indemnity Agreement extends to all acts of negligence by Releasees, INCLUDING NEGLIGENT RESCUE OPERATIONS and is intended to be as broad and inclusive as permitted by the laws of the State of Virginia or the state in which the activities are conducted and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Your signature below acknowledges that you have read and agree to the above waiver.
Signature *

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Printed Name *
Date *

Month Day Year

Emergency Contact information
Emergency contact *

First Name Last Name
Relationship to you: *
Phone Number *

Area Code Phone Number
Dietary Restrictions
Food allergies? *
If 'Yes', please specify *
Do you require other dietary restrictions? *
If 'Yes', please specify *

Registration Submission
Please note the following refund/cancellation policy...

A full refund minus $25 will be issued for cancellations 4 weeks or longer before the start of class. For cancellations 2-4 weeks prior to the start of class, a 50% refund will be issued. Any cancellations within two weeks of class will not be refunded.

If a student develops COVID-19 symptoms during the class, they will not be allowed to continue to participate and no refund will be issued.
Who is paying for this registration? *

Me, on my personal credit card My department/county will pay with their credit card.
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Student Registration - VEHEXT 2021 $ 200.00
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VEHEXT 2021 Registration Form

Coronavirus Policies

VEHEXT 2021 Registration

Emergency Contact information

Dietary Restrictions

Registration Submission