RIO HONDO COMMUNITY COLLEGE DISTRICT
RIO
11400 Greenstone Avenue  Santa Fe Springs  California  90670
Tracy Rickman, Fire Academy Coordinator  (562) 941-4082
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Department of Public Safety - Fire Technology
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Class ______
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FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Last Name _________________________________ First Name _________________________M.I. ____
Address:______________________________________________________________________________
Number
Home Phone: (
Street
) _______________________ Cell Phone: (
Birthdate: _____ / _____ / _____

Male

 Pre-Service
City
Female
State
Zip Code
) __________________________
Email: _____________________________________
RHC ID # ___________________________________
 In-Service / Sponsored by Agency: _______________________________________________
Signature: _________________________________________ Date _______________________________
Items required on separate sheets of paper:

Sponsorship Form (optional)

Coursework-in-Progress Form (if needed)

Physical Examination Form (2 pages)
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Medical Insurance Verification Form
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Copy of your Medical Insurance Card (if you have insurance); enlarge to 150%

Copy of your Drivers License; enlarge to 150%

Questionnaire

Course Verification: Once you have secured ALL the items above, your academic requirements
must be verified by Dr. Jennifer Fernandez, Public Safety Counselor at the Rio Hondo Fire Academy
11400 Greenstone Avenue, Santa Fe Springs. No appointment necessary; first come, first served,
ONLY on the following dates:
November 30 and December 1 (0800-1800)
December 3 (0900-1700)
RIO
Department of Public Safety - Fire Technology
11400 Greenstone Avenue  Santa Fe Springs  California  90670
Tracy Rickman, Fire Academy Coordinator  (562) 941-4082
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RIO HONDO COMMUNITY COLLEGE DISTRICT
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BASIC FIRE ACADEMY
IN-SERVICE AND SPONSORSHIP VERFICATION
I hereby certify that _______________________________________________ is a bonafide:
IN-SERVICE CADET
 Fully paid member of a governmental or industrial fire protection or fire prevention agency.
I also certify that this individual will be provided with worker’s compensation insurance by my
agency for any injury suffered during the course of the academy.
 Completed a Certified EMT-1 course with at least a “B”
SPONSORED CADET
 Auxiliary member of a department which:
Has completed:
 Certified EMT-1 course with at least a “B”
 Rio Hondo College Fire Technology Core Courses with a grade “C” or better
 FTEC101  FTEC102  FTEC103  FTEC104  FTEC105  FTEC106
 Rio Hondo College:  Math 30  English 35  Reading 23
with a grade of “C” or better
Signature: ________________________________________________
Date: ___________________________
Fire Chief
Chief’s Printed Name: __________________________________________________________________________
Department: _____________________________________ Phone Number: (
) _______________________
RIO HONDO COMMUNITY COLLEGE DISTRICT
RIO
11400 Greenstone Avenue  Santa Fe Springs  California  90670
Tracy Rickman, Fire Academy Coordinator  (562) 941-4082
NDO COLL
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Department of Public Safety - Fire Technology
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COURSEWORK IN PROGRESS VERIFICATION
Date: __________________
Last Name: _____________________________
First: _______________________________
Birthdate: __ __ / __ __ / __ __
Student ID #: __ __ __ __ __ __ __ __ __
* Use ONE form per college. Photocopy additional forms as needed.
Name of College:
Semester:
 Fall
 Spring
 Summer
Year: ___________
INSTRUCTOR: Tentative grades are needed for the above named student who is applying for the
Rio Hondo College Fire Academy. For online courses, please email coursework in progress directly
to student for processing.
COURSE #
COURSE TITLE
UNITS
GRADE TO DATE
A B C D F CR NC
A B C D F CR NC
A B C D F CR NC
A B C D F CR NC
A B C D F CR NC
A B C D F CR NC
A B C D F CR NC
A B C D F CR NC
INSTRUCTOR’S PRINTED NAME
AND SIGNATURE
RIO HONDO COMMUNITY COLLEGE DISTRICT
Class ______
DEPARTMENT OF PUBLIC SAFETY – FIRE TECHNOLOGY
RECORD OF MEDICAL HISTORY AND PHYSICAL EXAMINATION
(To be filled in by student. Please use ink and print clearly.)
NAME: _______________________________________________________________________
DATE: ____________________________________
PERMANENT ADDRESS: _______________________________________________________
TELEPHONE: ______________________________
Street
______________________________________________________________________________
City
State
STUDENT ID: ____________________________________
Zip Code
DATE OF BIRTH: ___________________
PLACE OF BIRTH: _____________________________
SOCIAL SECURITY NO: __________________________
FAMILY PHYSICIAN: ___________________________________________________________________________________________________________________
Name
Address
Telephone
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEALTH HISTORY
Check conditions you have had or now have. Show dates on non-chronic conditions.
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Allergies
Anemia
Arthritis
Asthma
Back Pain
Bladder Conditions
Bronchitis
Cancer
Chicken Pox
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Convulsive Disorder
Crohn’s Disease
Diabetes
Dizziness
Draining Ear
Fainting
Gall Bladder Disease
Headaches (Frequent)
Headaches (Migraine)
 Rheumatic Fever
 Seizures
 Smoking Habits
Packs Daily:  1  2  3
 Stomach Conditions
 Thyroid Disease
 Treatment for Alcoholism
 Treatment for Drug Addiction
 Ulcers
Heart Trouble
High Blood Pressure
Impairment of Hearing
Kidney Trouble
Marked Fatigue
Nervous Breakdown
Other Blood Diseases
Palpitation
Pneumonia
List any other illness you have had. (include dates) ____________________________________________________________________________________________
List medications. Prescribed: _____________________________________
Over the counter taken regularly: ___________________________________________
Surgical Procedures. (Give date and nature) __________________________________________________________________________________________________
Severe Accidents, including fractures. (Give date and nature) ____________________________________________________________________________________
Female Menstrual Disorders _______________________________________________________________________________________________________________
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IMMUNIZATIONS
Indicate which vaccinations and immunizations you have had. (Give dates) (WRITTEN proof of immunization is required)
NOTE: A Tetanus Diphtheria booster is required if none has been received within the last 10 years.
MMR 1 _______________
MMR 2 ___________
Titer Results ___________
Influenza
Hepatitis 1 ____________
Hepatitis 2 ____________
Hepatitis 3 ____________
Titer Results _______________
Varicella 1 __________ 2 __________
Titer Results ________________
TB Test Date: _______________ Reaction: ______________________________
________________
Tetanus Diphtheria Booster ____________ (within past 10 years)
If TB skin test is positive, a chest x-ray is required.
CHEST X-RAY RESULTS Date:__________________ RESULTS ____________________
* Women should not receive the Rubella vaccine if they are pregnant or might become pregnant within 3 months. However, if you are vaccinated and then find out you were pregnant at the time, it should not be a
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. cause
. for
. concern.
. . .Rubella
. .vaccine
. .has never
. . been
. known
. . to.harm. an. unborn
. .child.
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REP: Center for Disease Control
 NO
 NO
Nurses Signature: ________________________________________________
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 YES
NURSE: Patient counseled regarding importance of not becoming pregnant within 3 months of vaccination?
Send to see primary medical physician if pregnant.
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Date: ______________________________
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FAMILY MEDICAL HISTORY
FATHER
Name
Place of Birth
Occupation
State of
Health
Age
If Deceased,
Cause of
Death
MOTHER
BROTHERS
SISTERS
LAST NAME: _________________________________________
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FIRST NAME: ________________________________________
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PHYSICAL EXAMINATION (To be completed by Physician)
General Appearance
Height
Weight
BP
Temperature
Skin
Ears
Eyes
Throat
Teeth
Neck
Pulse
Respiration
Chest / Lungs
Heart: Before Exercise
After Exercise
Abdomen
Rectal Exam
Genitalia
Hernia
Pelvic and Breast Exam (on females)
Pregnancy Test  +  -
Female cadets must have a Urine Pregnancy Test.
Back Dorsal Spine
Extremities
Neurological
Additional information: ______________________________________________________________________________________________________________
Recommendations: __________________________________________________________________________________________________________________
HEARING
250
500
1000
VISION SCREENING
2000
4000
Right
6000
Right
Uncorrected
Left
Corrected
Left
Color Vision
 Glasses
Wears
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Audiometrist:
Examiner:
Date:
Date:
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 Contact Lenses
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CHEM PANEL INCLUDES URINALYSIS: Date: ________________________
This client has been examined and found physically acceptable for a Basic Fire Academy Training Program.
YES
 NO
Examining Physician: __________________________________________________
(Signature)
Date: ___________________________________
Provider Printed Name: ________________________________________________
Phone:___________________________________
RIO HONDO COMMUNITY COLLEGE DISTRICT
Department of Public Safety – Fire Technology
Class ______
____
INSURANCE VERIFICATION
Name: __________________________________________________
Home Phone: ____________________________________
Address: ___________________________________________________________________________________________________
Soc Security No.: __ __ __ - __ __ - __ __ __ __ Student Identification No.: __ __ __ __ __ __ __ __ __ DOB: __ __/__ __ /__ __
Do you have medical insurance?  Yes
 No
 Is this insurance the  Primary Insurance or  Secondary Insurance?
Insurance Co: _________________________________________________________________
Policy holder’s name: _________________________________________________
Policy No: _________________________
 Individual  Group  HMO
Relationship: __________________________
Group No: _________________________
Member No: _________________________
Ins. Co. Address: _____________________________________________________________________________________________
Does your place of employment provide this insurance?  Yes
 No
If yes, Employer’s Name: _________________________________________
Phone: ___________________________________
Address: ___________________________________________________________________________________________________
Are you covered by any other medical insurance(s)?  Yes
 No
 Is this insurance the  Primary Insurance or  Secondary Insurance?
Insurance Co: ________________________________________________________________
Policy holder’s name: __________________________________________________
Policy No: _________________________
 Individual  Group  HMO
Relationship: __________________________
Group No: _________________________
Member No: _________________________
Ins. Co. Address: _____________________________________________________________________________________________
 Is this insurance the  Primary Insurance or  Secondary Insurance?
Insurance Co: ________________________________________________________________
Policy holder’s name: _________________________________________________
Policy No: _________________________
 Individual  Group  HMO
Relationship: ___________________________
Group No: _________________________
Member No: _________________________
Ins. Co. Address: _____________________________________________________________________________________________
I hereby certify that the foregoing answers I have designated to the stated questions are true, complete, and correct to the best of my
knowledge.
__________________________________________________
Signature
___________________________________________
Date
NDO COLL
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Department of Public Safety - Fire Technology
11400 Greenstone Avenue  Santa Fe Springs  California  90670
Tracy Rickman, Fire Academy Coordinator  (562) 941-4082
RIO
RIO HONDO COMMUNITY COLLEGE DISTRICT
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QUESTIONNAIRE
Last Name: ___________________________ First: _____________________ M.I. _______
1. Have you ever served in the American Armed Forces?
If so, what branch of service? ___________________________
 Yes
 No
 Yes
 No
3. Have you ever served as a member of a Color Guard?
 Yes
 No
4. Have you ever been a member of a high school or college ROTC unit?
 Yes
 No
5. Have you ever been a member of a marching band?
 Yes
 No
6. Have you ever held a supervisory position?
 Yes
 No
7. Have you ever held a managerial position?
 Yes
 No
8. Would you consider yourself a leader?
 Yes
 No
9. Would you like to be in a position of leadership?
 Yes
 No
10. Are you as willing to take orders, as you are willing to give orders?
 Yes
 No
11. If in a position of authority, would you be able to make un-popular
decision without regret?
 Yes
 No
How long? __________
What was your military specialty? _________________________
2. Have you been a member of an Explorer Post?
If so, for what Fire Department _______________________
How long? ________________________________________