Application Packet. Winter 2019

Transcription

1 FIRE PROTECTION PROGRAM Application Packet Winter 2019 APPLICATION CLOSE: September 14, 2018 CLASSES BEGIN: January 7, 2019 Chemeketa Community College Brooks Regional Training Center, Building 2 PO Box Salem, OR

2 Your packet must include the following! Complete an Admission Application Form online at applyonline.chemeketa.edu A Chemeketa Placement test report showing recommended placement in: (For dates and times available call testing ) WR121 (completion of WR 115 or equivalent) MTH070 (completion of MTH060 or equivalent) RD115 (completion of RD090 or equivalent) A completed Fire Suppression Program Application with Personal Information Form and Affidavit (enclosed) Tobacco and Uniform Policy form Driving and Criminal Background form Applicant must provide copy of driver s license DMV certified copy of driving record in (unopened) sealed envelope. NO EXCEPTIONS. *Official High transcripts or GED Scores and Certificates in (unopened) sealed envelope. NO EXCEPTIONS. *College Transcripts, if applicable in (unopened) sealed envelope. NO EXCEPTIONS A completed Request for Evaluation and Transfer of Previous Credit Form (enclosed). A check or money order made out to Chemeketa Community College in the amount of $40.00 (Non-refundable)

3 All application material in one complete packet must be received or postmarked by 4:30pm September 14, 2018 to be considered for the Winter 2019 program. NO EXCEPTIONS. Chemeketa Community College Brooks Regional Training Center, Building 2 PO Box Salem, OR 97309

4 APPLICATION FOR FIRE PROTECTION AND DUAL DEGREE PROGRAMS PERSONAL INFORMATION FORM Name: CCC K #: Mailing Address: City, State, Zip Code Date of Birth: Home Phone: Cell Phone: Chemeketa address: PROBATIONARY STATUS Students enrolled in Emergency Services programs are required to perform work for payment in college credits. Fire Suppression and Fire/Paramedic students are assigned to duty shifts under close supervision. While on duty, students respond to actual emergencies and perform related work. Appointment to the Program is to a probationary status from which a student can be terminated for cause. Such cause may include, but is not limited to, failure to perform work of quantity or quality that complies with established work performance standards; failure to adhere to program rules, guidelines, or policies and procedures, any criminal activity or mental or physical conditions which would render the student ineligible to respond to emergency calls; positive result on, or the student's failure to submit to drug screening when that screening is required by programs staff for cause; or the student's failure to maintain a 2.0 grade point average. SMOKE-FREE COLLEGE POLICY The use of tobacco in any form is prohibited on or in all properties owned and or controlled by Chemeketa, including smoking in private vehicles while on Chemeketa property. Ignoring this policy may lead to a fine of up to $50.00, or expulsion from the Fire Program. Do you use tobacco? YES NO Can you adhere to this policy? YES NO

5 UNIFORM AND SAFETY STANDARDS The Fire Protection Program requires students to purchase and wear uniforms of a type worn by firefighters. Program policy prohibits the wearing of non-uniform clothing and most jewelry, including piercings, while on duty and while attending certain classes.

6 DRIVER LICENSE: Possession of a valid driver's license is required for acceptance to the Program. Additionally, students must be insurable by the insurance carrier of the college and the cooperating fire agencies. Students having three or more moving violations or chargeable accidents within the last three years, or one DUII within the last five years will not be admitted to the program. Do you have a valid Oregon driver s license or a driver s license from another state? NO YES STATE NUMBER Please list moving violations or chargeable accidents in the past 3 years. Date Please list any DUII s in the past 5 years Date CONVICTION OF A CRIME: Please list any criminal conviction, not including traffic infractions, sustained within the last 10 years. You will not be automatically excluded from consideration if you have been convicted of a crime. Your suitability for application will be evaluated based on the totality of circumstances, such as, the nature of the crime, the time since the conviction, etc. Conviction of a crime could also impact decisions by the Oregon State Health Division on your being certified as an EMT. All those admitted to the program are required to submit an official criminal history report. Have you ever been convicted of a crime? No Yes if yes, please explain: Date Crime convicted of

7 AFFIDAVIT AND AUTHORIZATION TO INVESTIGATE/HOLD HARMLESS I attest that all of the facts, dates and information that I have provided are true. Furthermore, I authorize investigation of all statements contained in my application, and, it is understood and agreed that any misrepresentation by me may result in cancellation of my application and/or termination from the Program. I authorize Chemeketa Community College to make any and all necessary and appropriate investigations to verify information given by me and to examine my fitness for participation in Chemeketa Community College Emergency Services Programs. I understand that these investigations will include both criminal and driving background. I hereby agree to release, defend, indemnify, and hold harmless, any person, company, or corporation as to any and all claims arising due to their supplying information pertaining to my suitability for application to the Chemeketa Community College Emergency Services Programs. Signature: Date:

8 REQUEST FOR EVALUATION AND TRANSFER OF PREVIOUS CREDIT Enrollment Center 4000 Lancaster Dr. NE P.O. Box Salem, OR Fax Student Information - ALL FIELDS REQUIRED FOR PROCESSING - (Please Print) Name Date K # This is your Chemeketa ID #. You must be an admitted student for previous credit to be evaluated and transferred to Chemeketa. You can find your K# on your student ID card or My Chemeketa. Address City State Zip Phone # ( ) Date of Birth SSN Previous Name(s) Used Reason You Are Requesting An Evaluation I am attending Chemeketa under Veteran Affair s (VA) benefits (Submit this form when enrolling for your first term at Chemeketa. VA regulations require that all prior credit be evaluated and reported by the end of your first term at Chemeketa.) I have applied for a degree or certificate at Chemeketa (Submit this form and your Application for Graduation by the end of the fourth week of the term prior to the expected term of graduation.) I am applying for a limited enrollment program at Chemeketa. (All Chemeketa programs are listed on the back of this form. Limited enrollment programs are designated with an *.) I am enrolling in a degree or certificate program and intend to graduate from Chemeketa. If you did not check one of the boxes above you do not need to have your transcript(s) evaluated and credits transferred to Chemeketa at this time. Please see Advising for additional information on your program of study and the effect of previous credits on the classes you will have to take at Chemeketa. s Providing Transcripts for Evaluation (Please Print) I have requested each of the above schools send official transcripts to the above address. I will hand deliver official transcripts in a sealed envelope to: Enrollment Center, Chemeketa Salem, Building 2, Room 200. Chemeketa is not required to accept all credits from other institutions. Submitted transcripts will not be returned or photocopied. Program You Are Enrolled in at Chemeketa (select from the list on the back of this form): PLEASE PRINT THE PROGRAM NAME Fire Suppression Please return completed form to: Enrollment Center, Chemeketa Salem, Building 2, Room 200 or Above Address C:\Users\chad\AppData\Local\Microsoft\Windows\Temporary Internet Files\Low\Content.IE5\N23J6DMU\Evaluation+Request+form [1].doc

9 Aquarium Science (1 year) * Aquarium Science (2 year) * Associate of Arts - Oregon Transfer (2 year) Associate of General Studies (2 year) Associate of Science/Or. Transfer Degree in Business (2 yr) Associate of Science ( 2 year) Accounting (2 year) Accounting ( 1year) Accounting Tax Preparation Apprenticeship Options Automotive Technology (2 year)* Automotive Tech - Automotive Body Repair (1 year) Automotive Tech Entry Level Tech (1 year) Automotive Tech - Automotive Machining (1 year) Building Inspection Technology (2year)* Business Tech - Accounting Admin Asst (2year) Business Tech. - Admin. Asst. Option (2 year) Business Tech. - Business Support Specialist (2 year) Business Tech. - Business Software Certificate (1 year) Business Tech. - Business Technology Certificate (1 year) Business Tech. - Office Fundamentals (1 year) Business Tech. - Medical Admin. Asst.(2 year) Civil Technology (2 year) Civil Technology - Survey Technology (1 year) Computer Systems and Information Technology (2 year) Computer Systems and Information Technology-Computer Programming (1 year) Computer Systems and Information Tech-Computer Security and Forensics (1year) Computer Systems and Info Tech-Support Specialist (1year) Computer Systems and Information Tech-Computer Sys Admin (1 year) Computer Systems and Information Tech-Database Developer (1year) Computer Systems and Info Tech-Web Developer (1 year) Criminal Justice (2 year) Criminal Justice - Basic Corrections (1 year) Criminal Justice - Basic Law Enforcement (1 year) Criminal Justice - Private Security (1 year) Dental Assisting (1 year) * Drafting Technology Architectural Drafting (1 year) Drafting Technology - CAD (2 year) Drafting Technology CAD Certificate (1 year) Early Childhood Education (1 year) Early Childhood Education (2 year) Early Childhood Ed-Infant/Toddler Career Pathway (1 year) Early Childhood Ed-Preschool Career Pathway (1 year) Elec. Tech. - Computer Electronics (2 year) Elec. Tech. - Electronic Engineering Technician (2 year) Elec. Tech. - Industrial Electronics (2 year) EMT - Paramedic (2 year) * FPT - Fire Service Supervision & Management (1 year) FPT - Fire Prevention (2 year) FPT - Fire Suppression (2 year) * Hlth. Serv. Mgt. - Health Info. Technology (1 year) Hlth. Serv. Mgt. - Health Services Mgt. (2 year) Hlth. Serv. Mgt. - Medical Transcription (2 year) Hlth. Serv. Mgt. Medical Transcription(1 year) Hlth. Serv. Mgt. Medical Coding (1 year) Horticulture (2 year) Hospitality Management (1 year) Hospitality Management (2 year) Hospitality Management - Event Management (1 year) Hospitality Management Spa Management (1 year) Human Services - Addiction Counselor Cert. Prep (1 year) Human Services - Addiction Studies Option (2 year) Human Services - Social Services Option (2 year) Juvenile Corrections Certificate (1 year) Juvenile Justice (2 year) Machining Tech Basic Manufact Tech-Welding Spec(1 year) Machining Tech--Basic Manufact Tech-CNC Mill Spec(1year) Machining Tech-Basic Manufact Tech-Machining Spec(1year) Machining Technology-CAM Fundamentals(1 year) Machining Tech-Computer Numerically Controlled Op(1 year) Machining Technology-Manual Machine Oper(1 year) Machining Technology-CAD/CAM(2 year) Management (2 year) Nursing Ed I Practical Nursing (1 year)* Nursing Ed. II - Associate Degree in Nursing (2 year) * Pharmacy Technician (1 year)* Pharmacy Management(2 year)* Retail Management (1 year) Speech Language Pathology (1 year)* Speech Language Pathology (2 year)* Tourism and Travel Management (1 year) Tourism and Travel Management (2 year) Tourism & Travel Management- Destination Marketing (1 yr) Vineyard Management (2 year) Vineyard Operations (1 year) Visual Communications (2 year)* Welding (1 year) Welding Fabrication (2 year) Winemaking (2 year) Wine Marketing (2 year) *- Limited Enrollment Programs C:\Users\chad\AppData\Local\Microsoft\Windows\Temporary Internet Files\Low\Content.IE5\N23J6DMU\Evaluation+Request+form [1].doc