2. Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Primary Phone Number*
12. Occupation
14. Emergency Contact*

    In the event you have a medical emergency or other type of emergency, please provide an emergency contact name and phone number to notify. 

15. Minimum Age Requirement*

    Participants in North Metro Fire's Community Academy must be at least 18 years of age. If you are 18 years of age or older, please affirm by checking the box below. 

    1. Yes, I am at least 18 years of age.
17. Please explain briefly why you wish to enroll in North Metro Fire's Community Academy.*
19. Will you be able to attend at least 80% of the Community Academy, which is necessary to receive a certificate of completion? Unforeseen emergencies will be recognized. *

    1. Yes
    2. No
21. If you can't attend 80% of the sessions, please explain.
23. Upload photo identification

    Please upload a copy of your photo identification (i.e., driver’s license, military ID, State ID Card) to this application. If you are unable to do so at this time, please send a copy to Pam Kutchen through email (pkutchen@northmetrofire.org) or mail to Pam Kutchen, 101 Spader Way, Broomfield, CO 80020. Your application will not be considered until a copy of your photo ID is received.

25. Shirt Size*
    -- Select One --Extra SmallSmallMediumLargeExtra Large2XL3XL

    Each academy participant will receive a North Metro Fire T-shirt to wear. Please let us know what size you prefer we order for you. 

27. Statement of Agreement

    Please review your answers carefully and read the statement below before signing this application. I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements. I understand any omission or false statements on this application may result in rejection of enrollment or dismissal from the North Metro Fire Community Academy. I understand that North Metro Fire will conduct a thorough criminal history and background check. By accepting a seat in North Metro Fire’s Community Academy, I hereby give permission to the Cities of Northglenn and Broomfield and North Metro Fire to use photographs from the academy sessions that may include my photographic images in public presentations and/or publications. I further understand that I will not receive compensation for the use of my photographic image in said presentations/publications. If you are satisfied with agreement and have completed your application in full, please provide an electronic signature below.

29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Electronic Signature
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field