Big Bend Community College
Aircraft Rescue and Fire Fighting (ARFF) Training Programs
Our mission is to provide the aviation community education and practical experience in Aircraft Rescue and Fire Fighting. By using the latest techniques each student will gain knowledge and experience in this complex emergency environment. They will take home the knowledge and confidence needed to perform effectively during an aircraft incident.
Big Bend Community College
ARFF Registration Form Page 2 3/1/17
For Office Use Only: Item Number:
/______
**Please Print Clearly**
Fire Department:
/______
/Training Date:
/______
Birthdate: Month Day Year / Personal Day Phone: / Personal Cell Phone:Last Name / First / Middle
Residential Address: Number & Street, Route & Box or PO / City / Zip
Gender: / ð FEMALE / ð MALE
ð Alaskan Native or Native American (597)
ð Chinese (605)
ð Vietnamese (629)
ð Japanese (611)
ð Korean (612)
ð Other Asian or Pacific Islander (621) / ð Hispanic (717)
ð Mexican, Mexican-American (722)
ð White/Caucasian (800)
ð African American (870)
ð Other Spanish/Latino (for example: El Salvadorian, Guatemalan, etc) / ð Other Race (specify) (622)
CIRCLE YOUR POSITION:
A. Airport Fire Department Personnel
B. Airport Volunteer Fire Fighter
C. Mutual Aide Fire Department / D. Military Fire Fighter
E. Fire fighter with interest
F. Other: ______
Have you Taken BBCC or CBIS classes previously? / ð Yes / ð No
Please list all previous personal names you may have registered at BBCC under, here:
Have you completed a 5-day class at BBCC? / ð Yes / ð No
OR Have you completed:
· At least 4 years of experience as a fire fighter AND
· At least 40 hours of initial and recurrent instruction per Part 139.319 Aircraft Rescue and Fire Fighting: Operational Requirements (j) Personnel AND
· Participated in at least one live fire drill
Signature:
CBIS ARFF Training Registration Form
ACKNOWLEDGEMENT of RISK
I am aware that while participating in the Aircraft Rescue & Fire Fighting training sponsored by Big Bend Community College, certain dangers may occur which are inherent in fighting/suppressing fuel fires with high pressure water and chemicals. Those dangers include, but are not limited to physical injuries which may result from equipment failure, use of hazardous and/or corrosive chemicals and exposure to intense heat and/or flames which may result in burns, physical contact with other individuals and/or firefighting equipment and/or wet or slippery walking conditions which may result in falls, cuts, abrasions, bruises, sprains, concussions, or fractured bones.
For the privilege of using the facilities of Big Bend Community College, and the Port of Moses Lake/Grant County International Airport, the undersigned, for ourselves, our heirs, administrators, executors, successors, and assigns, do hereby knowingly, willingly, and voluntarily assume all risks of accident, injury, or damage to ourselves or to our property. I agree to assume all responsibility, release, hold harmless Big Bend Community College, the Port of Moses Lake/Grant County Airport, and their officers, agents, and employees from all claims, loss, cost or expense for any injury or damage caused by me to other person(s) or property arising directly or indirectly out of the conduct of such course.
I hereby agree that I will secure and provide all necessary protective clothing and protective equipment OR use that protective clothing and equipment provided by the College.
This Acknowledgement of Risk covers the period of live fire and classroom training and any other dates that may be in any way connected with said course.
Student Signature Date
Page 4 3/1/17