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SIGNATURE OF AUTHORIZED LEGAL GUARDIAN DATE PRINTED NAME RELATIONSHIP TO FIREFIGHTER New York State Department of State Office of Fire Prevention and Control Training Authorization Letter DOS-1654 (5/04) To the Office of Fire Prevention and Control: The firefighter listed below is an active member of Fire Department and is authorized to attend the course indicated below. I understand this training course may contain certain evolutions that simulate and/or create actual firefighting or rescue conditions. The Office of Fire Prevention and Control is not responsible and/or liable for any malfunction or damage to any equipment used during this training program. SIGNATURE OF FIREFIGHTER DATE PRINT NAME OF FIREFIGHTER PRINT And, if firefighter is under the age of 18, the following consent must be provided: Additional copies of this form are available at http://www.dos.state.ny.us/fire/pdfs/authorization.pdf PRINT NAME OF FIREFIGHTER Fire FDID # Date Department Fill in YES or NO YES NO The firefighter listed below has medical clearance to use Self Contained Breathing Apparatus, (SCBA), in accordance with 29 C.F.R. part 1910. The firefighter listed below is authorized to use SCBA and participate in interior /exterior firefighting evolutions. If you cannot answer the questions above because you do not know the requirements of 29 C.F.R. Part 1910 or do not know whether the firefighter listed below is authorized to use SCBA, please contact your County Fire Coordinator or OFPC. PLEASE PRINT ALL INFORMATION Fire Chief Authorization Course Information Student Information Last First MI Name Address City State Home Work Zip Phone Phone Course Course Code # Title ( ) ( ) Print Chief’s Chief’s Name Signature PRINT NAME OF FIREFIGHTER I, , parent or legal guardian of consent to his/her participation in the training listed above. I have read, fully understand, and agree with the above information. I understand and acknowledge that safety is important during the training course and further authorize the instructor to remove from the simulation or course if the instructor believes that his/her behavior or abilities may cause a safety risk to himself/herself or another. I, , have read, fully understand and agree with above information. I understand and acknowledge the importance of safety during the training course and further acknowledge that if an instructor believes that my behavior or abilities may cause a safety risk to myself or another, the instructor has the authority to remove me from the simulation or course.