TO:
All EMT-B Candidates
FRANK BABINEC
Fire Chief
The attached paperwork must be completed and returned to the Coral Springs Regional
Institute of Public Safety (Coral Springs Fire Academy) at the Donald A. Haupt, Jr. Training Center
th
located at 4180 NW 120 Avenue, Coral Springs, Florida, 33065, prior to being accepted.
Please pay special attention to the following items:
1.
Application for EMT-B
2.
Student Enrollment Agreement (3 pages) – Read entire agreement, sign and date.
3.
Medical Examination (3 pages + Flu Form (if applicable time of year)
As part of the application process, a medical history and physical examination are required for all
students. Medical records must be complete in order for a student to be allowed to participate in the
clinical portion of the Program. Physical exams, required Immunizations, TB test and/or Chest X-ray
must be taken and updated annually, or as required by the Program.
Falsifying any information on these forms is cause for dismissal from the Program.
a.
Page 1 - It is the student’s responsibility to turn in the completed medical history, and all of the
required supporting documents, to the Coral Springs Regional Institute of Public Safety. If you
have had a complete physical exam within the past year you may submit a copy of that report &
attach those reports to this medical history form.
b.
Pages 2 & 3 – Bring these pages to your physician when getting your exam. This medical
examination must be completed by a physician, surgeon, or physician’s assistant per ch. 458; or
an osteopathic physician, surgeon, or physician’s assistant per ch.459; or an advanced registered
nurse practitioner per ch. 464.The doctor’s signature, printed name, title, address, phone number
and date of exam must be legible and needs to be signed on page 2. Page 3 requires the
physician’s signature or initials multiple spots. School records showing all immunization are
acceptable proof of immunizations.
4.
Release and Waiver – to be signed by applicant and witness to applicants signature
5.
FC-DICE profile must be created. You must include the assigned ID on the Application for EMT-B.
6.
CPR Completion- Students must go to https://www.onlineaha.org/ register an account and complete the
online portion of BLS for Healthcare providers (Part 1) in order to sit for the skills portion (part 2) here at
Coral Springs Regional Institute of Public Safety. This certificate MUST be brought in for Orientation day or
you will be immediately removed from the roster.
7.
Background Check Application – Must be completed and submitted with $25 processing fee.
8.
ONE copy of each of the following must be submitted with your application:
a. United States High School Diploma, Official Transcripts or the equivalent
b. Proof of Age (Florida Drivers’ License, Birth Certificate or Passport)
c. Proof of current medical health insurance card
9.
Acceptable Forms of Payment:
a. VISA/MC – cardholder must be present in order to process this form of payment. No Cash or
personal checks. * OR *
10. Tuition of $1,250.00 will be due in full by an assigned date prior to the first day of class.
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
READ THIS BEFORE COMPLETING ENROLLMENT APPLICATION
FRANK BABINEC
Fire Chief
EMERGENCY MEDICAL TECHNICIAN – BASIC (256 HOURS)
This Emergency Medical Technician - Basic is a mentally, physically, and emotionally challenging program that
includes extensive classroom and practical elements. The day course runs for approximately 14-16 consecutive
weeks meeting Tuesday and Thursday from 9am until 5:00pm. The evening class runs approximately 15 to 17 weeks
meeting on Tuesday, Wednesday, and Thursday evenings from 6:00pm – 10:00pm. Classes are held at the Donald
A. Haupt, Jr. Training Center (Fire Academy), located at 4180 NW 120 Ave, Coral Springs, FL, 33065. All class
sessions are presented regardless of weather conditions and no absences are permitted.
REGISTRATION
The Coral Springs Regional Institute of Public Safety (Coral Springs Fire Academy) at the Donald A. Haupt, Jr.
th
Training Center, 4180 NW 120 Ave., Coral Springs, Florida 33065, will accept completed applications during
specified dates which will be posted on the school website. ONLY correctly completed applications will be accepted.
All others will be returned to the applicant. Course registrations are NOT accepted by telephone, and we DO NOT
accept applications by mail. Required medical information must be submitted. Your medical form will expire in twelve
(12) months. Again, all incomplete applications will be returned to the student.
FEES
Unless otherwise indicated, all fees must be paid with VISA/MC or money orders/ cashier’s checks made payable to
Coral Springs Fire Dept. Please PRINT your name and complete address on all cashiers check / money order
payments.
Application Processing Fee:
$100.00. Must accompany completed application (non-refundable).
CPR/Healthcare Provider:
$45.00. Must accompany completed application & online course completion certificate
from AHA BLS Healthcare Provider (non-refundable).
Background Check Fee:
$25.00. Must accompany completed application (non-refundable).
Tuition:
$1250.00. Must be paid in full by specified date (prior to start of class) $100
(non-refundable) supplies, hospital manuals & shirt
Transfer Policy:
Located in the Course Catalog and Student Reference Guide. You can find this
on the www.coralspringsfireacademy.org under Resources.
Refund Policies:
Please refer to the Student Enrollment Agreement Form within this application.
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
General Student Checklist
Completed Application
FRANK BABINEC
Fire Chief
Medical (3 pages + Flu Form (if applicable time of year)
Page 1- Completed & notarized
Page 2- Completed & signed by provider
Page 3- Immunizations include MMR, Varicella, Hep B, Tetanus & PPD
Flu Form (October-April ONLY)
Copy of High School Diploma or Official Transcript or GED
Copy of Florida Driver’s License or Birth Certificate or Passport
Copy of Medical Insurance card
Signed Student Enrollment Agreement
Release & Waiver
Background Check Application
FC-DICE Number (on application)
$170.00 Payment (MC/Visa/Money Order/Cashier’s Check)
(1) $100.00 Application Processing Fee
(2) $25.00 Background Check Fee
(3) $45.00 CPR Healthcare Provider Skills Portion
VA Students Only:
DD-214
Certificate of Eligibility
Form 1990 or 1995
College Transcripts
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
CORAL SPRINGS REGIONAL INSTITUTE OF PUBLIC SAFETY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
FRANK BABINEC
Fire Chief
Application for EMT-B (256 Clock Hours)
Please type or print legibly.
Name:
First
MI
Home Address
City
State
FCDICE
Telephone Number (including area code)
White
Last
Hispanic Black
Race
Other
Cellular Phone
Date of Birth
Zip
M or F
Gender
E-mail Address
You must complete the online AHA CPR- BLS for Healthcare Providers course at
www.onlineaha.org in order to receive your certificate and do the skills portion at our facility. The
online portion costs $22.00 (to be paid online to AHA) and the skills portion costs $45.00 (to be
paid to Coral Springs Regional Institute of Public Safety.
The Coral Springs Fire Department Training and Public Education Division will keep your
application for one year from your date of application. After one year, the file will be discarded.
I agree to accept email/phone call notifications from the Coral Springs Fire Academy for future
classes.
Signature of Applicant
1
Date
Please refer to FCDICE instructional page on how to obtain this number.
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
MEDICAL HISTORY AND PHYSICAL EXAMINATION FORMS
1.
2.
3.
4.
5.
6.
As part of the application process, a medical history and physical examination are required for all students. Medical
records must be complete in order for a student to be allowed to participate in the clinical portion of the Program.
Physical exams, required Immunizations and Titers, TB test and/or Chest X-ray must be taken and updated every 6
months, or as required by the Program.
The student must provide all of the information requested on this package and then have this form notarized in the space
provided. The following pages are to be completed by the Examiner/Physician.
It is the student’s responsibility to turn in the completed medical history, and all of the required supporting documents, to
the Coral Springs Regional Institute of Public Safety.
If you have had a complete physical exam within the past year, you must have the physician transfer the information to this
medical history form.
Falsifying any information on these forms is cause for dismissal from the Program.
To be filled out by the student – Please print clearly
Name: ____________________________________________________________________________________
Last
First
Middle
Address: __________________________________________________________________________________
Street
City
State
Zip
Home phone: __________________________________ Work phone: ______________________________
Emergency Contact Name & #: _______________________________Relationship: _____________________
Have you had/Do you have
Hay Fever
Hepatitis A
Hepatitis B
High Blood Pressure
Dizziness or Fainting
Rheumatic Fever/Heart Murmur
Convulsion/Epilepsy
Diabetes
Disease/Injury of Joints
Back Problems
Physical Limitations
Additional comments
Yes
No
If yes, please comment
To be signed in front of a Notary
Signature: _______________________________ Date: ___________________
Parent’s Signature: _______________________________ Date: ___________________
(if student is under 18)
State of Florida
County of ___________________________________
The foregoing instrument was acknowledged before me this __________ day of __________ 20_____
By: _____________________________________________________
(stamp)
_________________________________________________________
Notary Public – State of Florida
Personally Known ( ) OR Produced Identification ( ) Type of Identification ___________________________
Page 1 of 3
NAME: ______________________________________
Examiner/Physician: Please examine this student as you would for a routine check-up. This student
will be working closely with people in acute-care settings and in the community.
Please
indicate/comment on any abnormal findings; use additional sheets if necessary.
HEIGHT: ____________ WEIGHT: ____________ BLOOD PRESSURE: ___________
SYSTEM
NORMAL
FINDING
COMMENTS/PREVIOUS
CONDITIONS/SURGERY
Eyes/Ears/Nose/Throat
Endocrine/Metabolic
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Integumentary
Can Student Participate in unlimited Physical activities in the clinical area?
Yes
No
Is Student now under treatment for any medical, surgical or emotional condition? Yes
No
Is the student now taking any medications?
If yes, what do you recommend?
Yes
No
Does the student require any follow-up health supervision?
If yes, what do you recommend?
Yes
No
Provider Identification
Provider Name (please print):
____________________________ Phone: _____________
Address: ___________________________________________________________________
Street
City
State
Zip
Signature of MD/DO/ARNP ______________________________________ Date: ________
License # __________________________________
Page 2 of 3
NAME: __________________________________
IMMUNIZATION INFORMATION FOR THE STUDENT
The Coral Springs Regional Institute of Public Safety EMT-B and Paramedic Programs require that all students be knowledgeable
regarding their immunization status for the common childhood diseases of Measles, Mumps and Chickenpox. Students must provide
immunization records as specified below.
TO THE PHYSICIAN / EXAMINER:
The information is required from each student entering the EMT-B or Paramedic programs at the Coral Springs Regional Institute of
Public Safety. Your cooperation in completing this form is essential.
You must obtain your immunization records that include the following vaccines: (You may provide School Immunization Record
as proof)
Date(s) Given:
Physician Initials:
Varicella
*Rubeola (Measles)
*Mumps
*Rubella (German Measles)
*or MMR(in lieu of Rubeola, Mumps 1
_____________
Rubella) (two shot series)
2
______________
Proof of Flu Vaccine for present years Flu Season (October – April) **see flu form**
Tetanus Toxoid Booster (Required within 10 years)
Date Given: __________________
Examiner/Physician Initials: _________________
Hepatitis B Vaccine
st
Dates Given: 1 : _______________ 2nd: _________________ 3rd: _____________________
-OR-
Effective August 1993, vaccination for Hepatitis-B is required. A student who opts not to receive the hepatitis series will be
required to sign a waiver form, thereby indicating their refusal to obtain the vaccines.
Declination
I, __________________________ acknowledge that by signing below, I understand that I may or may not be immune to
Hepatitis B. I am aware that I may be exposed to this disease during my clinical /ride time rotations and know the risks
involved. I decline the Hepatitis B Vaccination at this time. If in the future I receive the required vaccines I will submit a copy
to Coral Springs Regional Institute of Public Safety.
Student’s Signature: _______________________________________________________
PPD
Results shall not expire through the duration of the program.
Date given: _________________ Date Read: ________________
Circle one: Positive or Negative
Medical personnel signature: _____________________________________________
•
A positive PPD must be followed by a Chest X-ray within 2 days of a positive skin result, with results attached.
CHEST X-RAY* Date _______________
•
ATTACH RESULTS
Students who had a BCG Vaccine shall have a Chest X-Ray done and a copy of the report attached to this form
• Note: A Quantiferon Gold Lab result showing a ‘Negative’ result will be accepted in place of a
‘Negative’ PPD
Page 3 of 3
ONLY REQUIRED DURING THE MONTHS OF OCTOBER THROUGH APRIL
Name: _________________________________________________
FRANK BABINEC
Fire Chief
Dear Student,
This letter is to inform you that with your participation in the EMT/Paramedic Program you will be required to complete
hours for on-site Hospital Clinicals where you will be potentially coming into contact with sick people.
Below are facts about Influenza:
•
•
•
•
•
•
•
Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than
200,000 persons in the United States each year.
Influenza vaccination is recommended for all healthcare students and workers to prevent influenza disease and
its complications, including death.
If someone contracts Influenza, they will shed the virus for 24-48 hours before Influenza symptoms appear.
Shedding the virus can spread influenza infection to patients and co-workers in this facility.
If someone becomes infected with Influenza, even when their symptoms are mild, they can spread severe illness
to others.
The strains of the virus that cause Influenza infection change almost every year, which is why a different
Influenza vaccine formula is recommended each year.
A person cannot get the Influenza disease from the Influenza vaccine.
The consequences of refusing to be vaccinated could endanger your health and the health of those with whom
you’ve been in contact with, including:
o
o
o
Patients and staff in this healthcare setting
Your family
Your community
Broward Health and Tenet (Florida Medical Center) request that all participating in Hospital Clinicals at their facilities
receive an annual Influenza vaccination in order to protect themselves, the staff and the patients they encounter.
Therefore you MUST be vaccinated between the months of October thru April (Flu Season). Proof of the vaccination is
required. Below are the acceptable methods of providing proof:
1. Receipt from Walgreens, CVS, Publix etc… attached to this form
2. Paperwork from employer that provided the vaccine
3. Personal physician’s office/Urgent care facility must fill out the below:
Date vaccine was given: ________________________ Administered by: ____________________________________
Provider Name (please print): ________________________________________ Phone: ___________________________
Address: ________________________________________________________________________________________________________
Street
City
State
Zip
Signature of MD/DO/ARNP: ______________________________________________ Date: _________________________
License #:___________________________________________
* If you are NOT vaccinated, you MUST have a valid medical reason and provide
proof from a licensed physician.
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
CORAL SPRINGS REGIONAL INSTITUTE OF PUBLIC SAFETY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
STUDENT INFORMATION
Name:
Last
Home Address
CORAL SPRINGS FIRE ACADEMY
STUDENT ENROLLMENT AGREEMENT
First
MI
City
State/Zip
FRANK BABINEC
Fire Chief
Contact Number
Email Address
EMERGENCY MEDICAL TECHNICIAN - BASIC (256 Clock Hours)
CLASS SCHEDULE: ☐ NIGHT CLASS 17 WEEKS
☐ DAY CLASS 15 WEEKS
START DATE: ________________________ ANTICIPATED END DATE:
___________________
CANCELLATION AND REFUND POLICY:
Should student be terminated or cancel for any reason, all refunds will be made according to the following
refund schedule:
1. All refundable monies will be refunded if the school does not accept the applicant or if the student
cancels within three (3) business days after signing the enrollment agreement and making initial
payment.
rd
2. Cancellation after the third (3 ) business day, but before the first day of class, will result in a
refund of tuition only paid.
3. Cancellation after attendance has begun, but prior to 40% completion of the program, will result in
a pro-rated tuition refund computed on the number of hours completed to the total program hours.
4. Cancellations/Dismissal after completing 40% of the program will result in no refund. A letter will
be emailed to the student with further explanation.
5. The termination date for refund computation purposes is the last date, based on hours attended,
of actual attendance by the student.
6. Refunds will be processed within 30 days of termination or receipt of Cancellation Notice.
7. In order to receive a refund, student must return the academy issued photo ID card
a. Or submit a police report with case number in place of card along with current
replacement value.
b. Or submit a police report with case number in place of card and current replacement
value will be deducted from total refund.
8. Should the academy have to cancel any courses prior to starting, students will have the option of
a full refund of all monies paid, or to have guaranteed enrollment in the next course with no
additional fees.
9. For those students who sustain an injury outside of the program, before completing 40% of the
program, shall have their money refunded at the current pro-rated rate for any of the allotted time
not used and upon clearance of a physicians be allowed into the next class of the students choice
at full cost of the program. Should a student sustain an injury after completing 40% of the
program, there will not be a refund.
Page 1 of 3
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
FRANK BABINEC
Fire Chief
**CRIMINAL BACKGROUND CHECK (Non-refundable)
HEALTHCARE PROVIDER CPR (Non-refundable after completion)
REGISTRATION FEE (Non-Refundable)
MANUALS (STUDENT & HOSPITAL) 1 POLO SHIRT (Non-refundable)
TUITION
TOTAL COURSE PRICE
$ 25.00
$ 45.00
$ 100.00
$ 100.00
$ 1,250.00
$ 1,520.00
METHODS OF PAYMENT
1. VISA/MASTER CARD – cardholder must be present in order to process this form of payment.
*CANNOT BE USED AS DEBIT.
2. Cashiers’ Checks or Money Orders ONLY accepted.
o Made payable to: Coral Springs Fire Department.
o **Please PRINT your name, complete address and the last four of your SSN on
all payments. No cash or personal checks.
PAYMENT OPTIONS:
1. Full payment at signing of enrollment agreement. ($1,520.00)
2. Fees paid at signing of enrollment agreement ($170.00)
1. $100.00 registration
2. $25.00 background check
3. $45.00 CPR fees
With balance paid one week prior to class starting date. ($1,350.00)
NOTE: All fees and tuition must be paid prior to class starting date or student will be
removed from class roster.
FINANCIAL AID: Financial aid is not available.
There are no carrying charges, interest charges or service charges connected with the programs.
Upon successful completion of the program, the school will counsel and assist each graduate with job
placement; however the school does not guarantee employment. A Certificate of Completion will be
issued to each student who successfully completes the program and satisfies all requirements.
______
GROUNDS FOR TERMINATION
I agree to comply with the rules and policies and understand that the school shall have the right to
terminate this contract and my enrollment at any time for violation of rules and policies as outlined in the
catalog. I understand that the school reserves the right to modify the rules and regulation, and that I will
be advised of any and all modifications.
GRADUATION REQUIREMENTS
I understand that in order to graduate from the program and to receive a diploma, I must successfully
complete the required number of scheduled clock hours as specified in the catalog and on the Student
Enrollment Agreement, pass all written and practical examination with a minimum 75% but must maintain
an overall GPA of 80% and satisfy all financial obligations to the school.
Page 2 of 3
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
FRANK BABINEC
Fire Chief
NOTICE TO STUDENT: DO NOT SIGN THIS CONTRACT BEFORE YOU READ IT OR IF IT
CONTAINS ANY BLANK SPACES. YOU ARE ENTITLED TO AN EXACT COPY OF THE
CONTRACT YOU SIGN. KEEP IT TO PROTECT YOUR LEGAL RIGHTS.
ALL SIGNERS HAVE READ AND RECEIVED A COPY OF THE STUDENT ENROLLMENT
AGREEMENT AND CATALOG.
Student’s Signature
Date
Parent/Guardian if Student is under 18 years of age
Date
ACCEPTED BY:
_______
School Official
Date
Page 3 of 3
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
FRANK BABINEC
Fire Chief
RELEASE AND WAIVER
FOR CORAL SPRINGS REGIONAL INSTITUTE OF PUBLIC SAFETY TRAINING, TESTING,
AND/OR EDUCATION
In consideration for my acceptance to a training, testing, and/or educational program at the City of Coral
Springs, I agree to sign this Release and Waiver. Accordingly, I agree to unconditionally release, waive, and
discharge the City of Coral Springs, its Commission members, employees, agents, and servants, all hereafter
referred to as “releases,” from all claims and causes of action, that I, my personal representatives, assigns,
heirs, and next of kin, may have for any loss, damage, or injury to person or property, whether caused by the
negligence, or otherwise of the releases in connection with my participation in any training, testing, and/or
educational program at the City of Coral Springs. In addition, I agree to indemnify completely, the releases
against all claims, demands, made by or on behalf of me in relation to my participation in any training, testing,
and/or educational program and all causes of actions arising out of my own actions or involvement with the
City of Coral Springs.
The physical requirements for the training, testing, and/or education program that I want to participate in
have been explained to me and I certify and warrant that I am in good health and physical condition and able
to participate in all activities that may be required. I also understand that I may come into contact with
hazards, including but not limited to, blood borne pathogens, fire, and hazardous chemicals that may cause
great bodily injury or death. I fully realize and appreciate the foregoing risks and freely and voluntarily accept
those risks. Additionally, I agree to adhere to the applicable rules and regulations of the City of Coral Springs.
In addition, I authorize the City of Coral Springs or its agent to conduct a required criminal background check.
I understand and authorize the City of Coral Springs to disclose this information to any and all clinical sites I
may be involved with during my education at the City of Coral Springs. I understand and agree that I may be
denied entry into the program, or removed from the program, due to an unacceptable criminal background,
as determined by the City of Coral Springs, in their sole discretion.
I HAVE CAREFULLY READ THE FOREGOING RELEASE AND WAIVER AND KNOW THE CONTENTS
THEREOF AND HAVE SIGNED THIS RELEASE AND WAIVER AS MY OWN FREE ACT.
I expressly agree that this Release and Waiver is intended to be as broad and as inclusive as permitted by the
laws of the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall
notwithstanding, continue in full force and effect.
In Witness Whereof, I have executed this Release and Waiver on _____________________________________, 20___.
By: __________________________________________
Printed name of Signator
By: ___________________________________________
Signature
I asked the Signator if they understood what is being signed.
____________________________________________
Printed name of Witness
_________________________________________________
Witness signature
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
CORAL SPRINGS REGIONAL INSTITUTE OF PUBLIC SAFETY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
FRANK BABINEC
Fire Chief
☐ EMT Day
☐ EMT Night
☐ High School
☐ Paramedic
Background Check Application
Please type or print legibly.
Name:
Last
First
MI
Date of Birth
Street Address
City
St
Zip Code
SSN
Telephone Number (including area code)
Demographics:
☐ Male
☐ Black
☐ Female
☐ Hispanic
☐ White
☐ Other
The Coral Springs Regional Institute of Public Safety must notify individuals of the
circumstances that require or authorize the collection and use of social security numbers (SSN).
Florida Statute 119.71 (5) specifically authorizes the academy to collect SSN’s where required
by law or where the SSN is imperative in the performance of its duties. In this instance, the
academy is collecting the SSN for use in the proper identification and background screening of
students.
Social security numbers are kept confidential and will be securely maintained. SSN’s will not be
disclosed for any other reasons unless required by law or a court order.
Signature of Applicant
Date
☐ Completed (for Program Director only)
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
CORAL SPRINGS REGIONAL INSTITUTE OF PUBLIC SAFETY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423
Form CSRIPS BC-14-01-01
FRANK BABINEC
Fire Chief
FCDICE and You or Making It Easier – Student Login
FCDICE Student Login
This tutorial will guide you through logging in to the FCDICE system. This assumes you
have never been to this site before.
Login
• Go to www.floridastatefirecollege.org
Never Registered? You need to “Create New Account”
You will need to create a new account for yourself.
• On the home page, select “Create New Account”.
• This will start you through the new account process by verifying that your SSN is
not already on file.
• After SSN verification, provide your last name and DOB.
• Complete the registration process.
• When you reach the end of the process, be sure to select “Save”. Save will take
you to the In-Box page
Retrieving your FCDICE number:
• Log out.
• Log in again.
• Click CUSTOMIZE at the top of the page. Then click MY PROFILE. You will find
your STUDENT ID on that page. Please write the FCDICE # on your Medical
form and Certification page where it asks for Student ID. Keep this number with
you at all times. You will need this number for all future class registrations.
CITY OF CORAL SPRINGS, FLORIDA • CORAL SPRINGS FIRE DEPARTMENT
TRAINING AND PUBLIC EDUCATION DIVISION • CORAL SPRINGS FIRE ACADEMY
4180 NW 120 Ave • Coral Springs, FL 33065 • www.coralspringsfireacademy.org
Phone 954-346-1774 • Fax 954-340-4351 or 954-340-4423