Training Authorization Letter
(5/18)
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 Oce 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 INITIAL
PLEASE PRINT ALL INFORMATION
Course Name
Course Number Location
Last
Name
Address
New York
Training ID
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 Authorized
of Authorized Rep. Signature
PRINT NAME OF STUDENT
PRINTED NAME OF LEGAL GUARDIAN
SIGNATURE OF LEGAL GUARDIAN
SIGNATURE OF STUDENT
DATE
DATE
PRINT NAME OF STUDENT
- -
