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Training Authorization Letter The student listed below is an active member of the agency indicated below, is at least 16 years of age, 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. Course Information Student Information Agency Authorization COMPLETE THE APPROPRIATE SECTION BELOW ORIGINAL INITIAL PLEASE PRINT ALL INFORMATION Course Name Course Number Location First Name City Primary Phone MI State Zip The student listed below has medical clearance to use Self-Contained Breathing Apparatus (SCBA), in accordance with 29 C.F.R. part 1910.134 for courses as required. 16 or 17-year-old students must have the section below completed to participate in state fire training I, , have read, fully understand and agree with the 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. The undersigned 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 and further authorize the instructor to remove the student 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. 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 OFPC The student listed below is authorized to attend the training indicated Agency Name FDID # Date Print Name Original of Authorized Rep. Signature PRINT NAME OF STUDENT PRINTED NAME OF LEGAL GUARDIAN ORIGINAL SIGNATURE OF LEGAL GUARDIAN ORIGINAL SIGNATURE OF STUDENT DATE DATE PRINT NAME OF STUDENT Last Name Address New York Training ID Email Address EOSB - 1654 (4/23) Attachment A SIGN SIGN SIGN