Course Name: Trench Rescue Operations Refresher Course
Log Number: RESS-107-S007-2023
Class Start Date & Time: 04-11-2023 at 08:00
Class Location: Salisbury Fire Department Station 16

Please use complete legal name as shown on your photo identification.
Example: Joseph Jay Smith
Enter date in format: MM/DD/YYYY or select with pop-up calendar.
Example: 07/20/1969
Example: 123-45-6789
SID Number available from NFA at:cdp.dhs.gov/femasid/register
If you have forgotten your NFA SID you can find it at:cdp.dhs.gov/femasid/account/find
Example: 8811 60th Avenue

Example: College Park
Example: MD
Example: 20742
Example: US
Example: info@mfri.org
Example: 301-226-9900

If your agency is not listed in the list above and you do not work for a commercial ambulance service, please select "Unaffiliated". If you have any questions about the registration process please contact the MFRI LESRTC regional office. Contact information can be found at: https://www.mfri.org/lesrtc

RELEASE STATEMENT:

In compliance with the federal Family Educational and Rights to Privacy Act of 1974 and the Buckley Amendment, by checking the box below I authorize and give my permission to the University of Maryland, Maryland Fire and Rescue Institute, and the Maryland Institute for Emergency Medical Services Systems to release information concerning my training records to:

  1. the primary instructor of this course;
  2. the local training academy, if this course is being conducted within, or in collaboration with, such academy;
  3. and / or any federal or state agency (Maryland or other) with authority to certify, regulate, and/or fund EMS programs and personnel;

MFRI Course Acknowledgement Statement:

  1. I acknowledge that any fraudulent entry may be considered sufficient cause for rejection or subsequent revocation from this course.
  2. I understand the University of Maryland is not authorized to provide travel, medical, or health insurance for students. I maintain appropriate insurance on an individual basis. I will check my department's insurance policy to determine if I am sufficiently and appropriately covered.
  3. I understand that this registration is not to be regarded as an irrevocable contract between the student and the University of Maryland.
  4. I affirm and declare that I am physically and mentally fit to perform all tasks within this course.
Check box to acknowledge that you have read the statements above.

MFRI Operations Rules and Regulations:

You are required to read the MFRI Operations Section Rules and Regulations and then check the box.


Check box to acknowledge that you have read the MFRI Operations Section Rules and Regulations
By checking this box I give permission for MFRI to provide my contact information with the Maryland State Firemen's Association so they can provide me with information about benefits that are available to me.

If you do not check the box above your information will not be shared with the Maryland State Firemen's Association. To learn more about the benefits that are available to you from the Maryland State Firemen's Association visit their web site at: www.marylandvolunteer.org