219071 04/09/2013 CITY OF CARMEL, INDIANA VENDOR: 367056 Page 1 of 1
ONE CIVIC SQUARE TRI-COUNTY TRAINING ACADEMY
CARMEL, INDIANA 46032 311 EAST 6TH ST CHECK AMOUNT: $1,150.00
RUSHVILLE IN 46173 CHECK NUMBER: 219071
CHECK DATE: 4/9/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4357004 1, 150 . 00 EXTERNAL INSTRUCT FEE
v j
CARMEL FIRE DEPARTMENT
COURSE INVOICE
3/26/13
MED-TACT "SCHOOL OF TACTICAL MEDICINE
Course invoice for TACTICAL MEDIC COURSE JUNE 24-28 2013.
Course cost $ 575.00 X 2= $1,150.00
Lodging AND FOOD INCLUDED IN COURSE.
Payable to:
Tri-County Training Academy
311 East 6`" street
Rushville, In. 46173
765-932-3210
medtact @vahoo.com
www.medtactl.com
PAYABLE UPON RECEIPT.
NO REFUNDS GIVEN.
NEWFACT
( OOL O TACTIC I, IC EM CIN
CONSENT ,FORM
I UNDERSTAND THAT I WILL BE_ TRAINING. IN A POTENTIALLY
HAZARDOUS ENVIRONMENT AND DURING THIS COURSE I WILL
BE EXPOSED TO THE FOLLOWING CONDITIONS:
• BLANK FIRE WEAPONS
• PAINT BALLS
• PYROTECHNICS (DISTRACTION DEVICES)
• DARKENESS WITHIN HAZARDOUS FIELD ENVIRONMENT
• BEING HOUSED IN FIELD CONDITIONS
• SIMULATED TACTICAL OPERATIONS
• HARSH ENVIRONMENTAL CONDITIONS
1 understand that every effort will be made to ensure the safety of all participants, but the
possibility of injury exists. I also understand that designated emergency personnel will be on site
during training scenarios. I further state that I am in sufficient•physical condition to participate
in all PT sessions and training scenarios. I hold all participating agencies,the Tri-County
Training Academy, ME D__ staff,harmless for any injury or illness that may occur to myself
and agree that I am attending;this program on my own free will. I.also fully understand that I am
solely responsible for any medical cost that may occur to myself.
SIGNATURE: _/i>>���j�/ `' PRINTED NAME:
C
DATE: Oy J',ZL �)3 _ WITNESS:
I
TRI-COUNTY TRAINING ACADEMY
TACTICAL MEDIC COURSE
311 EAST 6TH STREET, RUSHVILLE, IN 46173
765-932-3210
www.medtactl.com
STUDENT APPLICATION
Date of Application: �? �a (13 _ SS#: 3(9°q 6-3 A(1
Name: ` ,��4��� -���t� DOB: 0 ") /7
to_
Address: 13`i3Lf 5pokw�.«� ` City: G•�,-�.�
State: _(,�,_ Zip: y�03"L
Home Phone: Cell: 3 I l S t3 '12- 15
E-mail: t� ac c�Mc( ,,� �� 18 Years Old? Yes .(- No
I agree to pay all tuition fees in full as agreed upon by academy staff:
SIGNATURE: w �.. �� v
EMERGENCY CONTACT INFORMATION:
Name:,,,,t t-� �� Relationship:
Contact Phone#: _711 S 0 _ Cell:
List Allergies if Any:
List Medications if Any: N /R
t
.r
TRI-COUNTY TRAINING ACADEMY
TACTICAL MEDIC COURSE
311 EAST 6TH STREET, RUSHVILLE, IN 46173
765-432-3210
www.medtactl.com
STUDENT APPLICATION
Date of Application: 3 A of 3 .._. SSri:
Name: �, (�� 6�, DOB: R / 7
Address: (��lC�c�.../71c�,ti�l,P: e� rises City':
State: __._._.._tu_��_�--_..�..�-_. ..,.
Zip: .Ll�o.3 ... . .. .. .. -
Home Phone: A Cell: 3 t 7 *39737
E-mail: lbn{1��w C �w ,,r,1 , �£,�� 18 Years Old? Yes ✓ No
I agree to pay all tuition fees in full as agreed upon by academy staff:
SIGNATURE: < < y
EMERGENCY CONTACT INFORMATION:
Name: EU,��', k l a ._. Relationship: 1-j
Contact Phone#: 3 ��.....(��y. .5 3 Cell:
List Allergies if Any: M (q_.
List Medications if A.ny: v .
I
SCHOOL OF TACTICAL NEUM"INE
CONSENT FORM
I UNDERSTAND THAT I WILL,-,.,BE TRAINING IN A POTENTIALLY
HAZARDOUS ENVIRONMENT AND DURING THIS COURSE I WILL
BE EXPOSED TO THE FOLLOWING, CONDITIONS:
BLANK FIRE WEAPONS
PAINT BALLS
PYROTECHNICS (DISTRACTION DEVICES)
DARKENESS WITHIN HAZARDOUS FIELD ENVIRONMENT
BEING HOUSED IN FIELD CONDITIONS
SIMULATED TACTICAL OPERATIONS
HARSH ENVIRONMENTAL CONDITIONS
I understand that every effort will be made to ensure the safety of all participants, but the
possibility of injury exists. I also understand that designated emergency personnel will be on site
during training scenarios. I further state that J am in sufficient physical condition to participate
in all-PT sessions and training scenarios. I hold all participating agencies, the Tri-County
Training Academy, MET)-Tact staff,harmless for any injury or illness that may occur to myself
and agree that I am attending,,this prograrn on my own free will. I also fully understand that I am
solely responsible for any medical cost that may occur to myself.
SIGNATURE: PRINTED NAME:
DATE: WITNESS:
VOUCHER NO. WARRANT NO.
ALLOWED 20
Tri-County Training Academy
IN SUM OF $
311 East 6th Street
Rushville, IN 46173
$1,150.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I I 43-570.04 I $1,150.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
APR m 8 2013
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Fagin-Benbow $1,150.00
1 hereby certify that the attached invoice(s), or bill(s), is(are)true and correct and I have audited same in accordance
with IC 5-11-10-1.6
, 20
Clerk-Treasurer