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 │ 518.474.6746 │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 Name
Course Number
Location
Agency Name
FDID #
Date
Authorized Rep
Signature
COMPLETE THIS SECTION FOR ANY COURSE REQUIRING SCBA USE
AND/OR PHYSICAL SKILLS BE COMPLETED
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.
Last
First
MI
Address
City
State
New York
Primary
( ) -
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
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