VIERA Registration and Consent Form - First Responder Training

Course Name

Is the Course Date Known?

Yes

Course Start Date

First Name

Middle Name

Last Name

Department Name

Email Address

Home Address

Consent to Release Information to EMALB

I hereby consent to allowing Vancouver Island Emergency Response Academy (VIERA) to release the following information to BC Emergency Medical Assistant Licensing Board – for the purpose of being registered as a qualified VIERA First Responder Instructor/Evaluator:

First Responder License Number

Consent to the above statement

I agree.

Consent to Release Information to Employer

I hereby consent to allowing Vancouver Island Emergency Response Academy (VIERA) to release to my employer my test results, Statement or Certificate of Course Completion and verification of attendance in connection with this course. I understand that my consent is required prior to release of the specified information.

Employer's Name

Employer Contact

Employer's Address

Consent to the above statement

I agree.

Consent from My Employer

I have been directed by my Fire Chief or supervising Chief Officer to register for this course. I understand that I can only register for VIERA courses if I have been given permission from my Chief Officer.

Consent to the above statement

I agree.

Officer's Name

Officer's Email Address

Emergency Contact Information

Name

Phone

Collection and use of your personal information

Information collected on this form is done so under the general authority of the Community Charter and Freedom of Information and Protection of Privacy Act (FOIPPA), and is protected in accordance with FOIPPA. Questions about the collection of your personal information may be referred to the Legislative Services Department at 250-755-4405, or via email at foi@nanaimo.ca. Please also see our Privacy Policy.

Last updated: April 19, 2023

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