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Please Note: No persons under the age of 16 may attend or participate in any training course delivered by the Office of Fire Prevention and Control. Additional copies of this form are available on the OFPC website: http://www.dhses.ny.gov/ofpc/publications/index.cfm#forms 1220 Washington Avenue, Bldg. 7A, Fl. 2, Albany, NY 12226 │ [PHONE REDACTED] │www.dhses.ny.gov/ofpc To the Office of Fire Prevention and Control: 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. PLEASE PRINT ALL INFORMATION Course Information Course Name Course Number Location Agency Authorization Agency Name FDID # Date Print Name of Authorized Rep Authorizing Signature COMPLETE THIS SECTION FOR ANY COURSE REQUIRING SCBA USE AND/OR PHYSICAL SKILLS BE COMPLETED YES NO Authorized Rep. Initials The student listed below has medical clearance to use Self-Contained Breathing Apparatus (SCBA), in accordance with 29 C.F.R. part 1910.134. The student listed below has the medical clearance to perform the skills required during this training course. The student 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 OFPC. Student Information Last Name First Name MI Address City State New York Training ID Primary Phone ( ) - Zip I, , have read, fully understand and agree with the above PRINT NAME OF STUDENT 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. STUDENT SIGNATURE DATE And, if the firefighter is 16 or 17 years old, the following consent must be provided: I, , parent or legal guardian of PRINT NAME OF PARENT/LEGAL GUARDIAN PRINT NAME OF STUDENT 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 from the simulation or course if the instructor believes that his/her PRINT NAME OF STUDENT behavior or abilities may cause a safety risk to himself/herself or another. SIGNATURE OF LEGAL GUARDIAN DATE PRINTED NAME DATE Training Authorization Letter to Participate in State Fire Training (4/18)