2016 VFF Course Request Form
User Manual: 2016-VFF-Course-Request-Form
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Revised 1/6/2016 Mississippi Volunteer Fire Training Programs Course Request Form (2016 Year) Select ONE (1) Program to Deliver per Request: CFRT ( ), Level-1 (___), Level-2 (___) HAZ-MAT A/O: NON-IFSAC (____) County Fire Coordinator Signature: ____________________________ County: ______________________ Lead Instructor: Name: __________________________________ E-Mail Address: ___________________________ Has the instructor completed Fire Instructor – I? Yes ____ No ____ Has the instructor completed the Volunteer Fire Fighter Instructor Orientation? Yes ____ No ____ Telephone Numbers: #1___________________________ #2 _______________________________ Mailing Address: ____________________________________________________________________ Course Information: (Mark ONLY ONE) Indicate which term you will be teaching in and the local Instructor should indicate the specific date, time and location. For VFF- Level I program, testing period of the term will be the last seven days of the term period. January 01, 2016 – March 31, 2016 Specific Written Test Date/Time________________________________ ___ March 01, 2016 – May 31, 2016 Specific Written Test Date/Time________________________________ ___ May 01, 2016 – July 31, 2016 Specific Written Test Date/Time________________________________ ___ July 01, 2016 – September 30, 2016 Specific Written Test Date/Time________________________________ September 01, 2016 – November 30, 2016 Specific Written Test Date/Time________________________________ ___ November 01, 2016 – January 31, 2017 Specific Written Test Date/Time________________________________ Written Test Location____________________________ Skill Test Date at MSFA (if applicable): ________________ Effective January 1, 2015 all registration documents and Test documents MUST be received by the registration deadline date (2 weeks before skill date) or skills date will roll over into next available Skill Test Date. TO BE READ AND SIGNED BY THE COURSE LEAD INSTRUCTOR: As the course lead instructor, I understand: Completed roll sheets for Module 1 and completed student applications for Module 2 must be forwarded to the MSFA immediately after the first class session. Any student added to the course must be done within one (1) week of the start of the course. Completed student activity packages must be received by the MSFA at least 3 weeks prior to the date of the written test. Any student not listed on the Module 1 roll sheet and not completing the course activities will not be allowed to participate in the written test. I must inform the MSFA course coordinator of any changes in the course, such as written test date. I must contact the MSFA course coordinator if I have questions. I agree by signing this request to maintain and adhere to any and all confidentiality requirements of testing materials both written and skills based. I understand that all registration documents including all Test Documents MUST be received by the registration deadline date or skills date will roll over into next available Skill Test Date. __________________________________________ ___________ Instructor Signature Return Completed Form To: Mississippi State Fire Academy Attn: Volunteer Fire Fighter Program #1 Fire Academy U.S.A. Jackson, MS 39208 FAX: 601-932-2819 dcollins@msfa.state.ms.us Date Local Instructor by e-mail (if applicable) ________________________________
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