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BC3 Fire and Hazmat Courses Form

 

 

Local Level Fire/Hazmat and Emergency Services Course Application

Pennsylvantia State Fire Academy Accredited and BC3 Classes

This form must be completed and mailed with payment to Butler County Community College, Public Safety, P.O. Box 1203, Butler, Pa. 16003-1203. The application must be received a minimum of 6 weeks prior to the proposed first day of class. This form must be filled out completely, printed and signed.

 

Part I: To be completed by requesting Fire/Hazmat or Emergency Services Agency requesting class.

 

 

Class Title: Respiratory Protection ll

 

Class Code: REPR Class Hours: 15 Class Fee: $200.00 Con Ed: Yes

 

* Denotes Required Fields

 

 

* Dept./Agency Name

 

* Contact Person

 

* Evening Phone * County

 

* Contact Person Street Address or P.O. Box number

 

* Contact Person City, State, Zip Code

 

* Day Phone

 

* Name of Proposed Instructor
  If you do not have an instructor, contact the program coordinator for a list of accredited instructors.

 

* Instructor Contacted

 

* Day Phone

 

* Evening Phone

 

* Email

 

 

Indicate dates, times and hours of class starting with the first day of class and ending with the last day of class.

 

Date mm/dd/yyyy Start Time End Time Hours

*

 

Total Hours

 

 

Physical and Mailing Address of Class - must be completed

 

* Department/Agency Name

 

* Street Address or P.O. Box Number

 

* City, State, Zip Code

 

 

Name and mailing address for person that Certificates should be mailed to

 

* Name

 

* Street Address or P.O. Box Number

 

* City, State, Zip Code

 

 

* Lead Instructor Name

Instr. Hours

 

Asst. Instructor Name

Instr. Hours

 

Asst. Instructor Name

Instr. Hours

 

Asst. Instructor Name

Instr. Hours

 

Asst. Instructor Name

Instr. Hours

 

Asst. Instructor Name

Instr. Hours

 

Asst. Instructor Name

Instr. Hours

 

 

Comments or Questions

 

Part 2: Terms and Conditions

1. The two page course application must be filled out completely and submitted with check payable to Butler County Community College 6 weeks priort to the first day of class.

2. The requesting agency can choose an accredited instructor to teach the class. If they do not have an instructor, they can request a list of instructors from the program coordinator to choose from. It will be the responsibility of the requesting agency to coordinate dates and times for class with the instructor prior to submitting the application.

4. All instructors must have signed contracts prior to instructing class. Instructors without contracts will not be paid by BC3 unless other arrangements have been made.

5. If the class requires manuals or other materials, the contact person for the agency must contact BC3 and the instructor at least two weeks in advance to let them know how many students are expected to attend the class. This will allow time for BC3 to send materials to instructor or the contact person.

5. The agency must notify BC3 in writing of the cancellation of a registered class within 48 hours of the class having been cancelled. Email will be accepted.

6. The class fee is non-refundable and forfeited if the class is canceled. The requesting agency can request a waiver to this rule by submitting a letter in writing explaining the circumstances connected to the cancellation. The letter of cancellation must be filed within 30 days of BC3 receiving notification in in writing by the agency of the class cancellation. A lack of students attending will not be accepted as a valid reason for fee reimbursement. The letter requesting reimbursment must be submitted to the Director of Workforce Development, Continuing Education Department, P.O. Box 1203, Butler, Pa. 16003-1203. The Fire and Hazmat Coordinator will not be permitted to approve fee waivers.

6. The decision to pay expenses to the instructors will be decided by the program coordinator dependent on available instructors in your area to instruct the class. If the agency is requesting someone from out of the area they may be asked to pay some or all of the instructor's expenses. This will be considered on a case by case scenario.

7. By signing this agreement the agency agrees to provide the proper classroom enviroment and necessary equipment to train on the lecture and lab skills necessary to complete the class. It will be the agencies repsonsibility to coordinate with the class instructor as to the needs of the class.

As the agent for the above mentioned agency I agree to abide by the terms and conditions of this agreement.

 

______________________________________________________________________________

Signature Title Date

 

 

______________________________________________________________________________

Program Coordinator     Date Approved    

 

 

 

CHECK MUST BE ATTACHED TO THIS FORM IN ORDER FOR CLASS TO BE PROCESSED