Form MA-823 Form MA-823 Supplementary Training Course Application

OMB Approval: 2133 0030

U S Department of Transportation
Maritime Administration

MAIL TO:

SUPPLEMENTARY TRAINING
COURSE APPLICATION

Maritime Administration
MD 3, Room W21-201
1200 New Jersey Avenue SE
Washington, DC 20590

Public reporting burden of this collection of information is estimated to average 3 minutes per response. Send comments regarding this burden estimate or
any other aspect of this information collection to the Maritime Administration, Office of Management and Administrative Services, MD 5, Room W28-201,
1200 New Jersey Avenue SE, Washington, DC 20590, and to the Office of Management and Budget, Paperwork Reduction Project (2133-0030),
Washington, DC 20503.

PRIVACY ACT NOTICE
This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), for individuals completing Form MA-823, Supplementary Training Course
Application. The collection of this information is authorized by 46 USC 1295 d and g. Purpose and Use -- The purpose of the MA-823 is to enroll individuals
in supplementary training courses offered by the Maritime Administration. The information will also be used as general statistical information on enrollment in
supplementary training courses. Effects of Nondisclosure -- The disclosure of this information is voluntary; however, the information is required in order to
enroll in supplementary training courses.

PLEASE COMPLETE THE FOLLOWING PERSONAL DATA:
1. Check One of the Following to Indicate the Course You are Applying
for:

Firefighting (Ship)

5. Merchant Marine Document Number:

6. Name of Employer/School

7. License Issue Number

8. License/Rating

Firefighting (Barge)

(Applicants for firefighting training must read NOTICE and sign
CONSENT AND RELEASE below)
Other (Specify)
Preferred Starting Dates: 1st Choice

FOR OFFICIAL USE ONLY
2nd Choice

1. Date Received

2. Dates Course Attended
From

To

2. Name and Address
3. Certificate No.

5. Remarks

2a. Telephone Number: (
)
3. Date of Birth (MonthlDaylYear)
4. Signature of Applicant

4. Date Fee Paid

Date

NOTICE
PARTICIPATION IN THE MARITIME ADMINISTRATION'S STANDARD FIREFIGHTING TRAINING PROGRAM (the ''Program''), AT TIMES, WILL
INVOLVE EXTREMELY VIGOROUS PHYSICAL ACTIVITY AND WILL INCLUDE, BUT IS NOT LIMITED TO, THE FOLLOWING EXERCISES:
• TO CONDUCT THE SEARCH AND RESCUE OF SIMULATED PERSONNEL CASUALTIES WHICH WEIGH APPROXIMATELY 150 POUNDS. THIS
. SEARCH AND RESCUE WILL OCCUR IN AN ENCLOSED SMOKE/FIRE ATMOSPHERE WHILE WEARING BREATHING APPARATUS.
• TO EXTINGUISH FIRES WITH AND WITHOUT THE AID OF BREATHING APPARATUS. THIS WILL INCLUDE MOVING QUICKLY AND CLIMBING
UP AND DOWN LADDERS WHILE HOLDING FIREFIGHTING EQUIPMENT SUCH AS HEAVY HOSES.
PARTICIPATION IN THIS PROGRAM CAN BE HAZARDOUS TO THE HEALTH OF INDIVIDUALS WITH CIRCULATORY PROBLEMS, HEART
AILMENTS, ALLERGIES (WHICH MAY BE TRIGGERED BY SMOKE, HEAT OR PHYSICAL ACTIVITY), OR RESPIRATORY PROBLEMS SUCH AS
EMPHYSEMA AND ASTHMA
Each participant is urged to consult with his or her doctor if any question exists regarding his or her physical ability to participate in the Program. Individuals
who feel that the Program may be hazardous to their health should not apply for or participate in the Program. The United States Government does not
provide insurance of any type for participants in the Program. The Maritime Administration reserves the right to deny training to or to terminate training of
any individual at any time when such training appears to constitute a hazard to such person or to others; in the event of such denial or
termination of training, the Maritime Administration will return all or the appropriate pro rata portion of any paid fee.

CONSENT AND RELEASE
I hereby affirm that by applying for enrollment in the Program I certify that I am aware of the inherent dangers and general health considerations in activities
connected with it.
I further understand and agree that it is not the function of the instructors to serve as the guardians of my health and safety. I also understand and agree, on
the behalf of me and my family, heirs, or assigns, that the United States of America, and its employees, agents and representatives, shall not be held liable
in any way for any occurrence in connection with my participation in the Program which may result in injury, death, or other damages to me.
In consideration of being allowed to enroll in the Program, I hereby personally assume all risks in connection with it, and I further release the United States
of America, and its employees, agents and representatives, including but not limited to the persons mentioned, for any harm, injury, or damage which may
befall me while I am enrolled in the Program, including all risks connected therewith, whether foreseen or unforeseen; and further to save and hold harmless
the United States of America, and its employees, agents and representatives, from any claim by me, or my family, estate, heirs, or assigns, arising out of my
enrollment and participation in the Program.
I further state that I am of lawful age and legally competent to sign this Consent and Release; that I understand the terms herein are contractual and not
merely recital; that I have fully informed myself of the contents of this Consent and Release by reading it before I signed it; and that I have signed this
document as my own free act.
In witness thereof, I have executed this Consent and Release at

on

,

20

Signature

FORM MA-823 (Rev. 11-2007)

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