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***DUE TO THE COVID-19 PANDEMIC AND FOR THE SAFETY OF ALL THE PARTICIPANTS, FULLY INVOLVED WILL BE CANCELLED FOR 2021***



CEDAR RAPIDS FIRE DEPARTMENT 
FULLY INVOLVED
Young Women's Fire Academy 2020
Application

The academy runs August 3rd - August 7th, 2020 and meets daily from 8:00 AM – 3:00 PM.
Registration begins February 15th, 2020, and ends June 30th, 2020.
There will be a $40 fee, payable by cash/check on the first day of the academy.  

Participant Information
Each field is required.  Please type N/A if it doesn't apply to you.

Participant's Name:

Home Address:

City:

Zip Code:

Cell Phone:

Email Address:

Date of Birth (MM/DD/YYYY):

Age:

Grade Entering:

School:

Occupation:


Please indicate T-shirt size:  

Can the participant commit to attending the entire program?  

Do you have turnout gear or have access to turnout gear?  



Parent/Guardian Information

Custodial Parent/Guardian Name:

Relationship:

Home Address (if different from above):

Home Phone:

Work Phone:

Cell Phone:

Second Parent/Guardian Name or Emergency Contact Name:

Relationship:

Home Address (if different from above):

Home Phone:




Medical Information

Allergies:  List all known allergies. Describe the allergic reaction and treatment for a reaction.

Dietary Needs:

Medications:  Please list all medications (including over-the-counter or non-prescription drugs) being taken.

General Health:  Please explain any medical conditions the participant has which the department should be aware of.

Provide any additional information about the participant's behavior, physical, emotional, or mental health.

Name of Family Physician:

Family Physician Phone:

Name of Family Dentist:

Family Dentist Phone:


Insurance Information: Is the participant covered by family medical insurance?  

If so, indicate carrier or plan name:

Group #:

Insurance Carrier Address:

Insurance Carrier Phone:


Are the participant's immunizations up to date?  

Is the participant certified in CPR?  


Typing your name and date in these boxes represents your signature.

Signature of Parent/Guardian (if required):

Signature of Participant:

Today's Date (M/D/Y):




Release, Waiver, and Hold Harmless Permission to Participate (“RELEASE”)

THE CITY OF CEDAR RAPIDS, IOWA REQUIRES THAT THIS RELEASE BE SIGNED BEFORE PARTICIPATION IN A CITY SPONSORED ACTIVITY. IF THIS FORM IS NOT SIGNED, YOU OR YOUR CHILD WILL NOT BE ALLOWED TO PARTICIPATE. IT IS A WAIVER OF RIGHTS. DO NOT SIGN IF YOU HAVE ANY QUESTIONS.

If the participant is a minor, both parents must sign this RELEASE. In the case of a single-parent home, the custodial parent must sign. If you are registering your child electronically, completion of the registration will be considered your consent and agreement with this document.

1.     You, for yourself and on behalf of your child hereby agree to release, waive, and hold harmless the City of Cedar Rapids, Iowa, its officers, agents, employees, volunteers, and, if applicable, contractors, sponsors, advertisers, owners and lessors of premises on which the activity takes place (Collectively referred to as “RELEASEES”), from any and all liability arising from participation in the following activity:

CEDAR RAPIDS FIRE DEPARTMENT – FULLY INVOLVED 2020

You agree that by signing this RELEASE you hereby agree to release, discharge, and covenant not to sue the RELEASEES from and for all liability, claims, demands, losses, or damages on your account caused or alleged to be caused in whole or in part by the negligence of the “RELEASEES” or otherwise, including negligent rescue operations; and you further agree that if, despite this release, waiver of liability, and assumption of risk you, or anyone on your behalf, make a claim against any of the RELEASEES, you will indemnify, save, and hold harmless each of the RELEASEES from any loss, liability, damage, or cost which any may incur as the result of such claim.

You acknowledge that you have read this RELEASE and understand that you have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature, and intend it be a complete and unconditional release of all liability, including any liability alleged to be caused by the negligence of the RELEASEES, to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.

2.     This RELEASE waives all claims, known or unknown arising out of participation in the activity, including injury or death to self, and damage to property, however, such claim may arise, including acts of negligence such as but not limited to negligent care, supervision, or control. This RELEASE waives any claims against the RELEASEES arising from the actions of any other participant in the activity. Further, this RELEASE covers all activities immediately before and after participation in the City Sponsored Activity, including transportation to and from the event and waiting for rides after the event.

3.     Participation involves a risk of injury. By signing this form, you represent that you have considered the risks of participation in the activity, have obtained any medical clearance necessary to participate, and are able to participate without harm to yourself or others. Any equipment or materials provided to the participant in conjunction with the activity shall only be used with due care for others, the equipment and the surroundings

4.     In the event of injury, program supervisors shall administer basic first aid, and shall summon emergency services via 911. Supervisors are not trained to provide detailed medical care, and shall not, without prior agreement, provide medications. All costs of emergency care are the responsibility of the participant/ participant’s legal guardian(s). NO INSURANCE IS PROVIDED BY THE CITY FOR INJURY TO PARTICIPANTS.

5.     You agree to follow all rules of conduct established in conjunction with the activity. Failure to follow the rules will result in your removal from the activity, and you agree that any program fees paid will be kept and not refunded. In the event of a problem while engaged in the activity, notify the activity manager/supervisor.

6.     This Release is given in partial consideration of your being allowed to participate in the activity described and binds yourself, your personal representatives, and any heirs or assigns.

7.     Media/Photo Release (please select a response):

  • The Cedar Rapids Fire Department may make audio or video recordings of the participant. You agree that photos or videos may be used in promotional materials/social media produced by the department to encourage participation in this activity.  
  • Members of various news media outlets may be on-site during the course of the week for the purpose of recording and reporting to the general public. This may include newspaper, radio, and television. You agree that your child may be recorded or interviewed.  
I HAVE READ THIS DOCUMENT CAREFULLY, AND UNDERSTAND IT. I AM SIGNING THIS FREELY AND WITHOUT RESERVATION OR CONDITION.

Typing your name and date in these boxes represents your signature.

Signature of Parent/Guardian (if required):

Signature of Participant:

Today's Date (MM/DD/YYYY):


© 2021  Cedar Rapids, Iowa, 101 First Street SE

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