( ) ( ) Fire Prevention and Control

signature of authorized legal guardian date

printed name relationship to firefighter

To the Oce of Fire Prevention and Control:

The ﬁreﬁghter listed below is an active member of _________________________________ Fire Department, 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 Oce 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

Please Note: No persons under the age of 16 may attend or participate in any training course delivered by the Oce of Fire Prevention and Control.

Additional copies of this form are available at www.dhses.ny.gov/ofpc/documents/authorization.pdf

print name of firefighter

Fire FDID # Date

Department

Fill in YES or NO

YES

The ﬁreﬁghter listed below has medical clearance to use Self Contained

Breathing Apparatus (SCBA), in accordance with 29 C.F.R. part 1910. 134.

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

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.

And, if ﬁreﬁghter is 16 or 17 years old, the following consent must be provided:

print name of firefighter

Training Authorization Letter

New York State Academy of Fire Science

600 College Ave., Montour Falls, NY 14865-9634

(607) 535-7136; Fax: (607) 535-4841

Fire Prevention

and Control

1654 (10/07)

The Training Authorization Letter is instituted to ensure that the student firefighter, fire chief/department

and the state fire instructor know that an individual has the authorization to attend the training course

or courses delivered by the New York State Division of Homeland Security and Emergency Services,

Office of Fire Prevention and Control and has obtained the necessary medical clearances to participate

in strenuous firefighter training activities. In addition, 16 and 17 year old firefighters must obtain approval

from a parent or legal guardian prior to attending and participating in any and all training courses deliv-

ered by the Office of Fire Prevention and Control. No persons under the age of 16 may attend or partici-

pate in any training course delivered by the Office of Fire Prevention and Control.

A letter signed by a chief officer of the student’s agency shall be submitted prior to participation in the

following training programs delivered by the Office of Fire Prevention and Control:

• Firefighter I

• Firefighter II

• Intermediate Firefighter

• Firefighter Survival

• Firefighter Assist and Search (FAST)

• Truck Company Operations

• SCBA Confidence

• Confined Space Rescue

• Passenger Train Rescue

• Hazardous Materials Technician - Basic

• Advanced Hazardous Materials Technician

• Flammable Gas Workshop

• Any new or future training courses requiring the use of Self Contained Breathing Apparatus (SCBA) or

Supplied Air Respirators (SAR’S) in accordance with 29CFR1910.134

Procedure:

1. Courses Requiring the Use of Self Contained Breathing Apparatus (SCBA) or Supplied Air

Respirators (SAR):

A. The student firefighter shall submit to the state fire instructor a completed Training Authorization Letter

signed by a chief officer and the student at registration for the first class session of any course requiring

the use of SCBA or SAR (courses listed above).

B. Any student firefighter that does not submit a completed letter will not participate in any evolution or

course session requiring the use of SCBA or SARs and will not receive credit for that session.

C. A Training Authorization Letter must be submitted for each course attended.

2. Course Attendance by 16 and 17 Year Old Firefighters:

A. Student firefighters 16 or 17 years of age must complete a Training Authorization Letter. This letter

must be signed by a chief officer, the student firefighter and parent or legal guardian and submitted at

registration for the first session of any course offered by OFPC.

B. Any 16 or 17 year-old student firefighter that does not submit a signed letter will not participate in the

course.

C. A Training Authorization Letter must be submitted for each course attended.

Outreach Training Guide

Appendix B-12

Training Authorization Letter Policy