Form Center • Montgomery County, PA • CivicEngage

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2. Fire Company Name*
3. County*
4. Station #*
6. Student Name
8. First*
9. Middle Initial
10. Last Name*
12. Student ID*
13. Date of Birth*
14. FEMA SID*
16. Course Name/Start Date*
17. Register for a FEMA SID:
19. Email Address*
20. Phone Number*
22. Home Address*
23. New address, email, or phone*

25. Name of Authorizing Officer*
26. Title*
27. Email Address of Officer*
29. Name of Training Officer*
30. Title*
31. Email Address of Officer*
35. Acknowledgement*

36. Student Initials*
38. </p> <div class="fr-view tip" style="font-family:Arial;font-size:10pt;color:#2b1506;font-weight:normal"> <p fr-original-style="" id="isPasted" style="margin: 0px 0px 1.4em; box-sizing: inherit; border: 0px none; font-family: Ubuntu; font-style: normal; font-weight: 400; color: rgb(60, 60, 60); line-height: 1.5;">I voluntarily assume all risk of loss, damage, illness or injury that I may sustain while participating as a student in Montgomery County Fire Academy activities.</p> <p fr-original-style="" style="margin: 0px 0px 1.4em; box-sizing: inherit; border: 0px none; font-family: Ubuntu; font-style: normal; font-weight: 400; color: rgb(60, 60, 60); line-height: 1.5;">I release the County of Montgomery and its officers, agents, and employees from any and all claims, demands, and causes of action on account of any injury or loss which may occur during my participation in Montgomery County Fire Academy activities, through negligence, omission, default or other action of any person or organization associated with such activities.</p> <p fr-original-style="" style="margin: 0px 0px 1.4em; box-sizing: inherit; border: 0px none; font-family: Ubuntu; font-style: normal; font-weight: 400; color: rgb(60, 60, 60); line-height: 1.5;">Individual Insurance: The County of Montgomery is not authorized to provide travel, medical, or Health insurance for students. You are advised to obtain appropriate insurance on an individual basis. If you are presently insured you should check your policy to assure yourself of sufficient and appropriate coverage.</p> </div> </div> </li> <li class="IePrintFormCenterField"/> <li class="third left Checkboxes formFieldContainer " data-external-submission-name="e_34"> <fieldset> <legend style="font-family:Ubuntu;font-size:10pt;color:#3c7498;font-weight:bold">Acknowledgement<span class="moduleContentNew">*</span></legend> <p><input id="h_34" name="fields[26].Key" type="hidden" value="34"/><input id="e_34" name="fields[26].Value" type="hidden"/></fieldset> </li> <li class="third right formFieldContainer ShortAnswer " data-external-submission-name="e_35"><label class="labelForFieldElement" for="e_35" style="font-family:Ubuntu;font-size:10pt;color:#3c7498;font-weight:bold">Student Initials<span class="moduleContentNew">*</span></label></li> <style type="text/css"><![CDATA[<![CDATA[ .FormCaptcha { visibility: hidden; display: block; margin: 0px; width: 0.1px; height: 0.1px; overflow: hidden; *height: 1px; *font-size: 1px; } ]]]]><![CDATA[>]]></style> <p> <br /> </p> <li/> <li class="left anonEmailCheckBox"> <br /> </li> <p> </p> <li class="left half anonEmail"> <br /> <label for="wantCopyAddress">Email address</label> <br /> </li> <p> <br /> <br /> </p> <li class="buttons"> <br /> </li> <p> <br /> </ol> <p class="moduleContentNew" id="liRequiredFieldInfo" style="display:none;">* indicates a required field</p> </div> <p> </p></form> <p><input id="dateFormat" name="dateFormat" type="hidden" value="M/d/yyyy"/></p> <link type="text/css" href="https://www.montgomerycountypa.gov/Content/2011.3.1115/telerik.common.min.css" rel="stylesheet"/> <link type="text/css" href="https://www.montgomerycountypa.gov/Content/2011.3.1115/telerik.vista.min.css" rel="stylesheet"/> </p></div> <p><br /> <br /><a href="https://www.montgomerycountypa.gov/4419">Source_link </a></p><div class='jnews_inline_related_post_wrapper right half'> <div class='jnews_inline_related_post'> <div 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