Fire Academy Application Please print legibly Application Due by November 30, 2017

Coastal Carolina Fire Academy 444 Western Boulevard Jacksonville, NC 28546 910-938-6823 firerescue@coastalcarolina.edu Fire Academy Application Please print legibly Application Due by November 30, 2017 I. Applicant Personal Information Name: Last First Middle Address: City: State: Zip Code: Telephone Home: Work: Cell: E-mail address: Social Security (last 4) #: or CCCC Student ID #: Date of Birth: T-Shirt Size: Have you ever had any felony or misdemeanor convictions including traffic violations: circle one Yes / No. If Yes, attach a page with description of convictions and dates. II. Educational Experience High School City/State Years Completed (circle one) 12 or High School Equivalency (Diploma or Transcript required with application) Technical School/College City/State Course Major Degree Years circle one 1 2 3 4 Other education: III. Work History Present or Last Employer Supervisor Name Employer Address Telephone Job Title Dates: From To Duties IV. References (not family) Name: Relationship: Phone# Name: Relationship: Phone# Name: Relationship: Phone#

Fire Academy Application Page 2 of 2 PLEASE PRINT LEGIBLY V. Commitment My initials below indicate that I understand that the Coastal Carolina Fire Academy consists of over 400 hours of training in more than 24 courses. This is a block-format Academy and students must meet attendance requirements for each individual course. I understand that if I am unable to meet attendance requirements of more than one of the courses I will be removed from the Academy program. I have been provided with the Academy Calendar via the Academy web page and understand that the calendar is subject to change based on weather and the needs of the College and Academy staff, but all efforts will be made to deliver the courses as indicated on the calendar provided. In a block formatted Academy, the student receives credit for all of the classes and the firefighter certification only when the entire Academy is completed successfully. If a student does not complete the Academy successfully they will not receive credit for any classes toward certification. Applicant Initials: Date: I have been provided with the Coastal Carolina Fire Academy Fees and Costs information sheet and acknowledge the information provided on that sheet. Applicant Initials: Date: I have received the information packet regarding the Coastal Carolina Fire Academy Physical Agility Test. I understand that participation in the test is part of the evaluation process for acceptance into the Academy. Applicant Initials: Date: I have received the TABE Test Information Sheet. I understand that participation in the test is part of the evaluation process for acceptance into the Academy. TABE test results must be included with the application. Applicant Initials: Date: Personal Statement On a separate sheet of paper please prepare a personal statement including why you wish to participate in the Fire Academy, your overall goals and objectives, and your views on the importance of training in a structured environment. Once complete, please attach your personal statement to your application for review. I have read and completed a personal statement addressing all questions indicated above. I understand that this will be reviewed as part of the evaluation process for acceptance into the Academy. Applicant Initials: Date:

I certify that the answers herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for the Coastal Carolina Community College Fire Academy as may be necessary in order to determine acceptance to the Academy. I understand that false or misleading information given in my application may result in discharge from the Academy. I also understand that I am required to abide by all policies and procedures of Coastal Carolina Community College and the Coastal Carolina Fire Academy. Entrance to the Fire Academy will be contingent upon satisfactory completion of all required forms. I give my permission for review of these forms by the Fire/Rescue Training Coordinator and appropriate staff as necessary. I also authorize the use of any photos or other media that may be taken during the Academy for the use of Coastal in its advertising. Printed Name: Signature: Date: PLEASE BE CERTAIN ALL INFORMATION IS INCLUDED AND RETURNED WITH PACKET. INCOMPLETE PACKETS WILL NOT BE REVIEWED FOR ACCEPTANCE INTO THE ACADEMY.

Coastal Carolina Fire Academy 444 Western Blvd. Jacksonville, NC 28546 910-938-6823 firerescue@coastalcarolina.edu Fire Academy Fees and Costs Information Cost- The Academy is delivered in a block format and requires a registration fee of $180 and an insurance fee of $1. The registration must be paid at the Orientation meeting. The cost of the text is approximately $95. The cost of uniforms is approximately $130. The amount of $26 will be due at the Orientation meeting for the purchase of Academy t-shirts. The cost of graduation uniforms will be due at an established date during the course of the Academy. At this time, the registration fees and associated costs are not eligible for VA/GI Bill benefits. A breakdown of the fees is indicated below. A financial aid scholarship is available for the Academy (see scholarship application). Students are required to provide their own uniform pants, shoes, belt, and socks outside of these costs. At this time we strongly encourage those interested in the Academy to become members of their local volunteer fire department. This can make you eligible for waived registration fees and give you access to the requisite PPE from the department. Eligible members of a NC volunteer fire department will need only to purchase the text and their uniforms. Proof of membership will be required. Course Information Cost Due Registration and Insurance ** $181 January 4 Initial Uniforms $26 approx. January 4 Textbook $95 approx. Prior to January 8 Graduation Uniforms $100 approx. Early April ** Members of NC fire departments are eligible for waiver of the $181 Registration and Insurance fee. Required Textbook: Essentials of Fire Fighting and Fire Department Operations, 6th Edition; Fire Protection Publications; 2013; ISBN: 978-0-87939-521-6 This text will be available at the Coastal Bookstore for a limited time.

Applicant- Please sign one of the following statements: I am applying for the Academy and I am currently a member of an agency that is fee-waived (fire department/rescue squad). Please use the provided Request for Fee Exemption Status form with your Chief s signature. I understand I will be responsible for textbook and uniform costs. Applicant Signature: Date: I am applying for the Academy, am not currently a member of a fee-waived agency, and will be paying my own fees and costs. Applicant Signature: Date: RETURN SIGNED COPY OF THIS FORM WITH YOUR APPLICATION.

Request for Fee Exemption Status Please submit this form to Coastal Carolina Community College along with a registration form. A new exemption status form and registration form are required each time the student registers for a class. If any student disassociates him or herself from the organization prior to the start of the class, please notify Coastal Carolina Community College immediately. The student must drop the class or pay the full registration fee. If you have any questions, please contact the Continuing Education office at 910.938.6294. Ref: a) NC General Statute G.S. 115B-2 b) NC General Statute G.S. 115-D 5(b) The following personnel is/are (a) member(s) in good standing of agency). (name of (circle one): PAID / VOLUNTEER FIRE PERSONNEL (list names) Please allow the above named personnel to register for Coastal Carolina Community College s Continuing Education class listed below: Class title: Dates: Location/ Duty Station: Fire Academy Block January 4 June 30, 2018 Coastal Carolina Community College These personnel should be exempt from paying registration fees as the course material directly relates to their job performance. Signature and Date Title Address of Organization/Duty Station Phone Number

Fire Academy TABE Testing Coastal Carolina Fire Academy 444 Western Blvd. Jacksonville, NC 28546 910-938-6823 firerescue@coastalcarolina.edu Applicants for the Coastal Carolina Fire Academy are required to take the TABE Reading test at the Continuing Education Building on campus. There is a significant amount of reading required to be successful in the Fire Academy and we hope to ensure success by selecting students who are academically prepared for the process. The test must be taken before the November 30 application due date. The location of the testing center is in Room 200 of the Continuing Education Building. The hours for TABE testing are 7:30 AM 7:00 PM, Monday Wednesday. No appointment is necessary. You must present a picture I.D. The test is timed and takes 25 minutes. Upon arrival at the testing center, you will advise the staff that you are testing for the Coastal Carolina Fire Academy. There is no required testing level. Your results will be used as part of the overall selection process. If your results indicate you may benefit from additional services provided by the college, the staff of the testing center may offer you the option of taking free classes to improve your skills and eventually raise your TABE test score(s). I understand the TABE Testing requirement for the Coastal Carolina Fire Academy. Applicant Signature: Date:

Coastal Carolina Fire Academy 444 Western Blvd. Jacksonville, NC 28546 910-938-6823 firerescue@coastalcarolina.edu Fire Academy Agility Test PHYSICAL AGILITY TEST INTRODUCTION Candidates for the Coastal Carolina Fire Academy are subject to strenuous physical activity as part of the program. Candidates for this Academy must be able to demonstrate such physical qualities such as strength, agility, and endurance. The physical agility test for the Academy measures three fundamental elements: strength, agility, and endurance. Candidates are advised to arrive for the test in running shoes and loose-fitting clothing, if possible. Because of the possibility of injury or strain in the testing process, the applicant is required to sign a waiver absolving Coastal Carolina Community College and the examiners of any liability for physical injury incurred by the applicant during the test. PHYSICAL AGILITY TEST The physical agility score is considered as part of the overall score in the selection process for the Fire Academy. The entire test must be completed in 12 minutes. The stopwatch will be stopped one time during the test, while the SCBA and helmet is placed on the candidate. 1. SIT-UPS (Stopwatch Starts) Starting Position: Candidate lies flat on back with knees bent, heels close to buttocks (approximately 10 inches) and arms folded across the chest, fingers to front of shoulders, and feet held to floor/ground by examiner. Sit up touching elbows to thighs. Lie back touching shoulder blades to floor. Action: Keeping knees bent and feet together, candidate raises body bending at the waist to a sitting position slightly beyond a 90 angle; then lower body to starting position and repeat twenty times. Minimum Passing Score: Complete twenty sit-ups. Note: This is a test for measuring the strength of the back and abdominal muscles. Candidate should not rest between sit-ups. 2. WALKING BALANCE BEAM Starting Position: The candidate will stand at the end of the balance beam and with a continuous walk must successfully reach the other end without falling. Minimum Passing: If the candidate falls off the beam, they may retry from the starting point. Note: This is a job related demonstration of agility. A firefighter often has to walk the edge of buildings, rafters, and joists in order to suppress fires and search for hidden fires.

3. FOUR-FOOT BARRIER Starting Position: The candidate moves to the barrier and must get over the barrier to the other side in any manner possible without the aid of any device or person. Candidate may not go around ends of barrier. Minimum Passing: If the candidate fails to get over the barrier, they may retry from the starting point until successful or 60 seconds have passed. If the applicant has not been successful in 60 seconds, they will move to the next station. Note: This is a job-related test. Firefighters in many instances have to go over fences or through windows or over other obstacles of comparable height or higher with the additional burden of wearing firefighting gear. 4. BODY DRAG Starting Position: Candidate approaches the body from the previous station. Action: Candidate must drag in any reasonable manner a (approximately 165 pound) victim or an item that is equal, 100 feet on a level grass surface without the aid of any device or person. Minimum Passing: Applicant must drag the body or item the entire distance. Note: This is a job-related test. It is designed to measure an individual s strength and endurance that may be necessary in performing one of the most important aspects for the job the ability to speedily rescue a person from an emergency environment. (Stopwatch stops when candidate reaches drill tower gravel while donning SCBA. Stopwatch starts when hose bundle is lifted from ground.) 5. STAIR CLIMB and HOSE RAISE WITH SCBA ON (WITH NO MASK) Starting Position: Candidate stands at starting line with hose bundle at candidate s feet. Hands may not be on bundle. Action: 1. Pick up the hose bundle at the starting line. (Stopwatch Starts) 2. Carry it to the stairway and walk up two flights of stairs, taking one step at a time 3. Place hose bundle on deck. 4. Raise separate hose bundle from ground using hoist rope and place on deck. 5. Pick up original hose bundle. 6. Proceed down stairs to ground level and return to starting line. Minimum Passing: Applicant must complete all steps above before proceeding. Note: This is a job-related test. Firefighters are required to carry or pull tools, hose, etc., to heights as part of normal firefighting operations. This test is a measurement of strength and agility. 6. ENDURANCE RUN Starting Position: Applicant begins behind starting line. Action: On GO candidate must run one-half mile on a relatively level surface. Minimum Passing: Candidate must successfully complete the course. Note: This is a job-related test. Firefighters must have sufficient cardiovascular endurance for physical firefighting tasks. This test is designed to test capability to do this and to test endurance. (Stopwatch stops)

Applicant s Statement: With my signature below I acknowledge that I understand that the Coastal Carolina Fire Academy Agility Test is an important element of selection for the Academy. I understand that I must attend one of the two agility test dates in order to be considered for the Academy. In agreeing to take part in the agility test process, I absolve Coastal Carolina Community College, its staff, employees, and volunteer evaluators of any liability for injury or illness as a result of the agility testing process. I will take my agility test at the following time (choose one): Monday, December, 4 2017 6 PM Thursday, December 7, 2017 6 PM Applicant Signature: Date: RETURN SIGNED COPY OF THIS FORM WITH YOUR APPLICATION.

Coastal Carolina Fire Academy Student Rules and Regulations 2017 Adherence to the following rules and regulations is essential to the efficient operation of the Coastal Carolina Fire Academy (hereinafter referred to as Academy ). All students will familiarize themselves with these rules & regulations and be held responsible for compliance. CONDUCT Students must conduct themselves in accordance with the Coastal Carolina Community College Catalog 2017-2018. Students shall be courteous, disciplined and consistent with the high ideals of the fire service. Proper decorum shall be observed at all times toward fellow students, Academy staff and instructors. Students are responsible for maintaining in clean condition any equipment and buildings made available for their use. The following are prohibited: Abusive, profane, or obscene language or behavior; horseplay or any disturbance during the class or while on the grounds of the college or training areas; any form of gambling, sexual harassment, use, possession or introduction of any intoxicants; and reporting to class under the influence of any intoxicants. Students will follow the chain of command at all times. The chain of command is Academy Student Lieutenant/Captain - Course Instructor Academy Coordinator. Students will rise to attention any time someone other than the Instructor or Academy Coordinator enters the training area, with the exception of during lecture/training times. In the absence of an Instructor, the Academy Captain will greet the visitor with, How can we help you sir, or ma am? ATTENDANCE The Academy class will be delayed or cancelled in accordance with the College s weather delays or cancellations. Weather schedule changes are available on the College website at coastalcarolina.edu Students are required to report to the assigned training location with all necessary equipment prior to the start of all classes. Late students are to report to the Course Instructor upon arrival to the Academy. Students will not leave the Academy prior to class dismissal without notifying the Instructor and receiving permission. Fire/emergency calls will not be considered an excuse for being late or missing a class. Academy students are required to maintain 80% attendance in each of the subjects as well as successfully pass written and practical exams in order to continue in the Academy. Any student who is consistently late to class may be dismissed from the Academy. Students are required to be present for class sessions covering practical skills training. Students who are absent from practical skills training sessions are subject to dismissal from the Academy. GENERAL Students will park in the Student Parking Lot according to the rules and regulations of Coastal Carolina Community College. A parking pass is not required. The use or possession of Alcoholic Beverages and Controlled Dangerous Substances are strictly prohibited.

Tobacco use is prohibited on the Coastal Carolina Community College campus and Georgetown Training Grounds. Electronic nicotine delivery systems are prohibited in buildings and entry ways. Only plastic bottled beverages are permitted in the classrooms. Eating is not allowed during classroom/training time but is permitted during breaks. All students shall police and clean up the Academy classroom and training ground as necessary or as directed by the Academy staff. Turnout gear shall not be worn inside the classroom building except as required for class. Alerting devices must be silenced during class. Students who are found using their cell phones will be excused for the remainder of the class session and will be counted absent. Personal texting and internet access may only take place during class breaks. Mobile computing devices (tablets, ipads, laptops) may be used for note-taking only, with the Instructor s permission. Photography and recording of video during training is only allowed if approved by the instructor. Any damage or loss to the student s mobile device/phone is the sole responsibility of the student. Dress code: Navy Blue BDU-style or work trousers. Jeans are prohibited. Pants are not to be tucked into boots. Academy T-Shirt o In cold weather if you would like a warmer shirt you may choose one of the following: Navy blue long-sleeve academy T-shirt Navy blue long-sleeve t-shirt under Academy T-Shirt Black shoes may be athletic or work shoe/boot style. Must be solid black. No loafers/casual shoes. If your uniform shoes are not steel-toe you MUST wear your fire boots for any skills as deemed necessary by the instructor. Plain black or navy blue socks Black belt with plain buckle After each class, the Academy Captain will complete the Captain s Report. The Captain will be responsible for e-mailing the Captain s Report to the Academy Coordinator. The details required in the report will be provided to the students at the beginning of the Academy. The Captain s Report must be sent to the Academy Coordinator within 24 hours of the end of each class. TESTING In the Academy block class a student who does not pass the first attempt at a certification test has the opportunity to retest. If a student does not pass the second attempt, the student will be dismissed from the Academy and will not receive credit for classes taken. This applies to both practical and written tests. Students have 30 days to schedule and complete a re-test with the Academy Coordinator. Any student who fails to complete a re-test within the 30 day window will be dismissed from the Academy. SAFETY Students will respond immediately to Instructors commands to protect themselves and their fellow students from accident or injury. Horseplay will not be tolerated. Any such conduct is grounds for dismissal from the class or the Academy. Students shall not engage in any non-sanctioned activity that endangers the safety of themselves, fellow students or instructional staff while at the Academy.

All protective clothing worn must meet NFPA & OSHA (Final Rule 29 CFR 1910.156) requirements. Students who have facial hair that interferes with an SCBA facepiece seal will not be permitted to participate in the Academy per OSHA rule. This applies at all meetings of all Academy classes. Students must report to Academy with PPE as required. Students will be informed of PPE needs prior to each class. Self- Contained Breathing Apparatus shall be worn by all students under the following conditions: Oxygen deficient or contaminated atmospheres Elevated temperature environments Below-grade training evolutions All students shall wear protective clothing during training evolutions at the discretion of the class instructor or in conformance with recognized safety standards. All student protective equipment will be removed from the training grounds and classroom at the end of each class session. The College s SCBA Fill Station will not be used until the students have received initial training, and then not without an Academy Instructor overseeing the process. Personal Alert Safety System (PASS) devices must be worn and active during all training evolutions where an IDLH atmosphere may be present. Jewelry will not be worn during live fire training. This includes earrings, necklaces, bracelets, and rings. Medic alert bracelets and necklaces are exempt. Any student participating in live fire training that comes to class with hair that extends past his or her collar, must arrange such hair so that it does not fall below the collar. Hair enclosed in an NFPA approved fire resistant hood is acceptable. Students shall report all injuries or illnesses to the Academy Coordinator or Instructor immediately. Students are advised to alert an instructor at any time they experience shortness of breath, chest pain, or excessive fatigue. Student must make an effort to stay hydrated and will be required to take rehab breaks as directed by the instructor. DRILL GROUND TRAINING The Incident Command System shall be implemented during all drills. All live structural fire attack evolutions shall be conducted in compliance with NFPA 1403, Live Fire Training Evolution in Structures, 2012 ed. A training evolution may be postponed if an unsafe condition occurs due to weather or if the condition of the Academy facility requires it. Use of live victims during live fire or smoke training evolutions is strictly prohibited. For other evolutions, live victims shall be fitted with appropriate harness and safety rope system as needed.

Student Commitment I have read and understand the Student Rules and Regulations for the Coastal Carolina Fire Academy. I will abide by these rules and regulations as well as the Coastal Carolina Community College Catalog and understand that violation may result in disciplinary action up to dismissal from the Fire Academy. Student Signature: Student Name Printed: Date: