State of Connecticut

Department of Emergency Services & Public Protection Commission on Fire Prevention and Control

1. 2017 Advanced Fire Investigation School 2. Burrville Fire School Offering Four Courses Beginning February 3. Retirement Celebration for Alan Zygmunt – Southington F.D. 4. Cohanzie Fire Department (Waterford) Hosting Forcible Entry Class 5. Emergency Operations Plan Training for School Districts & Schools K-12 6. 2017 Introduction to the Fire Service at the Connecticut Fire Academy - Deadline April 1, 2017 ---------- 1. 2017 Advanced Fire Investigation School The Connecticut State Police Fire & Explosion Investigation Unit, in cooperation with the CT Chapter IAAI and the Office of Education and Data Management, is pleased to announce the 2017 Advanced Fire Investigation School to be held at the Connecticut Fire Academy April 25 - 28 and May 2 - 5, 2017. Please refer to the attached Announcement and Application Form for details. All applications must be submitted by the deadline of March 10, 2017. The class is limited to 20 students. **Please note that there is a fee for this course and attendance at all sessions is mandatory** ----------- 2. Burrville Fire School Offering Four Courses Beginning February Introduction to Company Officer: The Program is directed toward new company officers or personnel who desire to seek company officer positions. Course content includes; Transition from Firefighter to Company Officer, Duties and Responsibilities of a Company Officer, Strategy and Tactics, Crew Supervision, etc. The program is eight (8) weeks in length, meeting one (1) night each week. The first class is being held at the New Hartford Fire Department starting on February 8th and will run until March 29th. This will be eight (8) consecutive Wednesday nights, each class will start at 1800 hours and

conclude at 2200 hours. The address for New Hartford Fire Department is 3 Greenwoods Road, New Hartford CT. The cost for the class is $165 per student. Marquam Johnson, Fire Chief (Ret.) will serve as the lead instructor for the Program. Assisting Chief Johnson will be a number of instructors with a vast variety of company officer experience. Firefighter 1: This will be hosted by the Goshen Fire Department. It will begin of February 21st and run on Tuesday and Thursday nights. Fire ground activities will be mostly on the weekends. Exterior Firefighter: A firefighting course for Exterior Firefighters will be hosted at the Woodbury Fire Department. It will comprise of 13 classes, some on Tuesday nights, some on Saturdays. Fire chiefs, this is a great way to get a new firefighter up to speed prior to taking Firefighter 1. It begins on March 18th. Cold Water Rescue: The Burrville Fire School will be holding a one day Cold Water Rescue class on March 4th at the Barkhamsted East Fire Department. The class will run from 0730 - 1630 hours. The eight hour program will provide students a review of cold water rescue operations, familiarization with cold water rescue equipment and an opportunity to utilize the equipment in cold water conditions. Instructors John Andryzeck and Bob Mangione will be the instructors for the Program. Cost per student will be $35. If interested please complete the attached application. Deadline for applications or the cold water rescue class is February 28th. Please spread the word and share this opportunity with members in your departments. Let’s fill the class! An application is attached for your convenience. Please forward completed application to Director Rich Winn (richard.t.winn@snet.net) or mail it to Burrville Fire Training School PO Box 335 Pleasant Valley CT 06063-0335. Please feel free to contact Director Rich Winn (860-309-4375 or richard.t.winn@snet.net) of Asst. Director John Field (860-806-3560 or ladder69@live.com). ---------- 3. Retirement Celebration for Alan Zygmunt – Southington F.D. A retirement celebration will be held for Battalion Chief Alan Zygmunt in honor of his 30 years of service with the Southington F.D. The event will be held on Friday, March 24, 2017 at Testa’s Banquet Facility 26 South Center Street in Southington, CT. Cocktail hour 6 p.m. with dinner/ceremony to follow at 7:00 p.m. A sit down style dinner with beer and wine included. $50 per person. Advance ticket sales only! Please contact 860-621-3202 Ext. 8234 or stop by Fire HQ, 310 North Main Street before Tuesday, March 14, 2017. Tickets are also available at the CT Fire Academy, please see Jason Decremer. See the attached. ---------- 4. Cohanzie Fire Department (Waterford) Hosting Forcible Entry Class

The Cohanzie F.D. in Waterford is hosting an open enrollment forcible entry class on Saturday, March 11, 2017. Cost is $125, PPE, ear and eye protection required, lunch is included. See the attached for course and registration information. ---------- 5. Emergency Operations Plan Training for School Districts & Schools K-12 This is a 1.5-day course, February 15 and 16, 2017 and being held at the Montville Police Headquarters, 911 Norwich New London Turnpike (RT 32), Uncasville, CT. These classes are to provide schools, school districts and their safety committees with the tools needed to produce a high quality multi-hazards emergency operations plan as mandated by Public Act 13-3. The class follows the G-364 FEMA curriculum modified for Connecticut. The following is a partial list of who should attend: Superintendents, Principals, School Business Manager, Police, School Resource Officers, Fire Marshal, Fire Chief, Nurse, Public Health, Emergency Manager, Risk Manager, Facilities, Food Service, Transportation manager and elected officials. As many of these positions mentioned are required to be part of the development of the plan and need to sign off on the plan annually, this course helps them understand how to develop the plan, test the plan, and maintain it. Registration for this course is thru the DEMHS Training Calendar at www.ct.gov/demhs. For additional information or questions, please contact William Turley at 860-685-8560 or William.turley@ct.gov. FM Credits: 12 hours ---------- 6. 2017 Introduction to the Fire Service at the Connecticut Fire Academy - Deadline April 1, 2017 Applications for the 2017 Introduction to the Fire Service at the Connecticut Fire Academy are now available on the CFPC website http://www.ct.gov/cfpc. Introduction to the Fire Service applications must be returned by April 1, 2017. There is also information on the webpage regarding the Introduction to the Fire Service Junior Counselors Program. These forms detail the procedure for graduates of past years ITTFS classes and graduates of the Advanced Skills and Concepts (ASAC) class to apply for an interview to be considered for a possible Junior Counselor position. Those applications must be returned by March 24, 2017. Additional information on these programs can be found at: http://www.ct.gov/cfpc/cwp/view.asp?Q=516050&A=832

The

Connecticut State Police Fire & Explosion Investigation Unit

and the

Connecticut Chapter of the International Association of Arson Investigators

in cooperation with the

Office of Education and Data Management

proudly present

at the Connecticut Fire Academy

April 25-28 and May 2-5, 2017

State of Connecticut Department Of Emergency Services and

Public Protection Connecticut State Police

Commission on Fire Prevention and Control

The 23rd AnnualAdvanced FireInvestigation

School

PROGRAM SCHEDULE

This comprehensive program incorporates classroom instruction with practical hands-on application. Students will conduct an investigation of an actual fire scene, prepare their own individual origin and cause report, and prepare their case with a prosecutor before testifying in a mock courtroom. This program is recognized by the IAAI as a tested course and meets the requirements of the Expert Witness Testimony Course offered at the National Fire Academy.

Fifty eight (58) hours of Continuing Education Credits will be awarded to all students who successfully complete this program. Points towards IAAI-CFI re-certification may be applicable to qualified students.

The cost of this course is $375 ($350 for CT IAAI members) and covers the cost of instruction, training materials, and all lunches, which are provided on campus. For more information on becoming a CT IAAI member visit http://www.iaai-ct.org DO NOT SEND REGISTRATION FEE WITH THE ENCLOSED APPLICATION

A committee will select twenty students from all applications received by the dead- line of March 10, 2017. Students selected will be notified by mail with additional instructions and pre-requisite requirements that must be completed prior to the first day of class. Registration fees must be received prior to attendance.

When: April 25-28 and May 2-5, 2017

Where:

Connecticut Fire Academy Windsor Locks, CT

Who Should Attend:

Certified Fire Officials; Police Officers involved

in fire investigation

Cost: $375.00

$350.00 for CT IAAI Members

A p p l i c a t i o n D e a d l i n e : March 10, 2017

Week One: April 25 - 28 Tuesday, April 25, 2017 0800 - 0830 Registration – Cafeteria 0830 - 0900 Welcoming Remarks Jeffrey J. Morrissette, State Fire Administrator, CT Fire Academy 0900 - 1145 Legal Issues & Preparing as an Expert Witness

Executive Assistant SA Michael Gailor, 1145 - 1215 Lunch - Fire Academy Cafeteria 1215 - 1700 Applied Fire Investigation Techniques

Roger Baxter, James Butterworth, Dets. John Sawyer, Paul Makuc and Wayne Opdenbrouw

Wednesday, April 26, 2017 0830 - 1145 Applied Fire Investigation Techniques (cont’d) 1145 - 1215 Lunch - Fire Academy Cafeteria 1215 - 1700 Applied Fire Investigation Techniques (cont’d)

Thursday, April 27, 2017 0830 -1145 Applied Fire Investigation Techniques (cont’d) 1145 -1215 Lunch - Fire Academy Cafeteria 1215 -1700 Applied Fire Investigation Techniques (cont’d)

Friday, April 28, 2017 Fire Investigation Practical - Burn Trailers 0830 - 1145 Fire Scene Investigation 1145 - 1245 Lunch - at Fire Scene 1245 - 1700 Fire Scene Investigation

Week Tw o: May 2-5 Tuesday, May 2, 2017 Report Writing 0830 - 1145 Case Preparation 1145 - 1215 Lunch - Fire Academy Cafeteria 1215 - 1700 Case Preparation (cont’d)

Wednesday, May 3, 2017 Trial Preparation 0830-1000 Preparing for the Defense 1000 -1145 Preparing for the Prosecution 1145 -1245 Lunch - Fire Academy Cafeteria 1245 -1600 Preparing for Prosecution 1600 -1700 A Judge’s Perspective

Thursday, May 4, 2017 Expert Witness Testimony 0830 -1000 Preparation with Prosecutors

1000 - 1200 Courtroom Testimony 1200 - 1230 Lunch - Fire Academy Cafeteria 1230 - 1530 Courtroom Testimony 1530 - 1600 Class Photo

Friday, May 5, 2017 0830 - 1200 Course Review 1200 - 1300 Critiques and Certificates

This program’s success would not be possible without the support of The Connecticut FAIR PLAN and the

Connecticut Chapter of the International Association of Arson Investigators

ABOUT THE PROGRAM

Michael Gailor, Executive Assistant State’s Attorney, Chief State’s Attorney’s Office Attorney Gailor graduated from UConn School of Law and became an Assistant State’s Attorney. He has worked as a prosecutor in Hartford since 1995, and lectures on testifying as an expert witness for IAAI and the Annual Fire School, as well as participating in the Fire School’s mock courtroom testimony.

James R. Butterworth, Retired Sergeant, Connecticut State Police, Office of State Fire Marshal Mr. Butterworth served with the Connecticut State Police Department for over twenty-one years. He retired with the rank of sergeant in 1995. In 1986, while assigned to the Canine Unit he was selected to be one of the two handlers and trainers for “Mattie,” a black Labrador Retriever considered to be the world’s first Accelerant Detection Canine. In 1990, Mr. Butterworth was promoted to the rank of sergeant and assigned as a fire investigation supervisor with the Office of State Fire Marshal. In 1992 he was promoted to Commanding Officer of the Bureau of Investigations and En- forcement. From 1995 to 2013 he worked as a private fire investigator. He has served as the program coordinator of the Advanced Fire Investigation School since 1998. Mr. Butterworth has testified as an expert witness in both state and federal court.

Roger A. Baxter, IAAI-CFI, Retired Detective, Connecticut State Police, Office of State Fire Marshal Detective Baxter retired from the Office of State Fire Marshal, Bureau of Investigations and Enforcement, where he had been assigned for more than 19 years. For 18 of those years, Roger was a Certified Accelerant Detection Canine Handler. Retired Detective Baxter has attended advanced courses in Fire Investigation and Courtroom Procedures and he has also taught many subjects for the Connecticut Fire Marshal Certification Program. Roger is a Certified Fire Inves- tigator with the IAAI and is now the owner of Acacia Fire Investigations. He has provided fire origin and cause expert witness testimony at criminal and civil trials.

John M. Sawyer, IAAI-CFI, Detective, Connecticut State Police Fire & Explosion Investigation Unit Detective Sawyer has been with the Connecticut State Police since 1997 and was assigned to Office of State Fire Mar- shal, Bureau of Investigation and Enforcement, in 2002. Since September of 2007 he has been a Certified Accelerant Detection Canine Handler, working numerous fire scenes with his assigned accelerant detection K-9’s “Lily” and “Sophie.” John has attended numerous advanced courses in fire and explosion investigations and courtroom proce- dures including the National Fire Academy Training Center in Maryland. He has provided fire origin and cause expert witness testimony at criminal trials. He also runs and coordinates the Connecticut Advanced Fire Investigation School and Vehicle Fire School and is the Past President of the CT IAAI Chapter.

Paul G. Makuc, IAAI-CFI, Detective, Connecticut State Police Fire & Explosion Investigation Unit

Detective Makuc has been with the Connecticut State Police since 2000 and was assigned to the Office of the State Fire Marshal, Bureau of Investigations and Enforcement in 2005. Since November 2008 he has been a Certified Accelerant Detection Canine Handler, working numerous scenes with his assigned K-9’s “Baxter” and “Cora.” Prior to coming to the Connecticut State Police, he worked with the Massachusetts State Police, Office of the State Fire Marshal. He is a member of the Board of Directors of the New England Fire & Explosion Seminar at Saint Anselm College in Manchester, New Hampshire and is the 2nd Vice President of the CT IAAI Chapter. He has attended numerous courses in advanced fire investigations and courtroom procedures offered at the FBI Academy in Virginia and the National Fire Academy in Maryland. He has provided fire origin and cause expert witness testimony at criminal and civil trials in state and federal courts and given numerous depositions.

Wayne A. Opdenbrouw, IAAI-CFI, CFEI, Detective, Connecticut State Police Fire & Explosion Investigation Unit

Detective Opdenbrouw has been with the Connecticut State Police since 2000 and was assigned to the Office of the State Fire Marshal, Bureau of Investigations and Enforcement in 2006. Since November 2008 he has been a Certified Accelerant Detection Canine Handler, working numerous scenes with his assigned K-9’s “Elway” and “Sprite.” He has earned numerous degrees from the University of New Haven, including Arson Investigation and Fire Science Admin- istration, and is a NAFI Certified Fire and Explosion Investigator. He has attended courses in advanced fire investiga- tion at the National Fire Academy in Maryland and instructs for the State of Connecticut Pre-Certification Class. He has provided fire origin and cause expert witness testimony at criminal trials and given numerous depositions. He is the Secretary of the CT IAAI Chapter.

PROGRAM INSTRUCTORS

2017 23rd ANNUAL ADVANCED FIRE INVESTIGATION SCHOOL APPLICATION

(OVER)

SECTION I - GENERAL INFORMATION (For office use only)

NAME (LAST, FIRST, MIDDLE INITIAL) PLEASE PRINT LEGIBLY

ADDRESS (Street, Town, State and Zip Code) OEDM ID NUMBER ___ ___ ___ - ___ ___ ___ ___

CELL PHONE NO. ( )

EMAIL ADDRESS (PLEASE PRINT LEGIBLY) WORK PHONE NO. ( )

DO YOU HAVE ANY HANDICAPS (including special allergies or medical conditions) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE AT THIS COURSE? NO ___ YES________________________

HAVE YOU ATTENDED THE ADVANCED FIRE INVESTIGATION SCHOOL BEFORE? NO____ YES ____ YEAR?_______

SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION

NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED

Enter your current position in Organization being represented and number of years in the position.

Position:___________________________

Years:_________

CHECK THE BOX BELOW TO INDICATE THE COUNTY YOUR ORGANIZATION IS LOCATED IN

FAIRFIELD HARTFORD

LITCHFIELD MIDDLESEX

NEW HAVEN NEW LONDON

TOLLAND WINDHAM

Briefly describe your activities or responsibilities as they relate to the course for which you are applying and identify how you will utilize the information obtained from the course:

CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION JURISDICTION TYPE OF ORGANIZATION AFFILIATION STATEWIDE CITY/TOWN/VILLAGE FIRE DISTRICT FEDERAL/MILITARY INDUSTRY/BUSINESS OTHER ___________________

CAREER VOLUNTEER COMBINATION

FIRE SERVICE LAW ENFORCEMENT EMERGENCY MGMT. JUDICIAL OTHER ___________________

2017 23rd ANNUAL ADVANCED FIRE INVESTIGATION SCHOOL APPLICATION

Do you investigate fires now? Yes No

Number of fires investigated __________________

List previous Fire Investigation courses you have attended (including National/Federal, State and Private sponsored courses). Attach additional page if necessary.

DEADLINE FOR SUBMISSION OF THIS APPLICATION IS MARCH 10, 2017

DO NOT send tuition fee with this application

Accepted applicants will be notified in writing after March 20, 2017

Please Note: ATTENDANCE AT ALL SESSIONS IS MANDATORY Class begins promptly at 8:30 am each day with registration at 8:00 am on the first day

Classes will run until 5:00 pm with the exception of the last day

SECTION III - RELEASE FROM LIABILITY I, ________________________________________, hereby acknowledge and agree that I will be covered by my personal or department's workers' compensation insurance coverage while participating in the above training course and that the Connecticut Fire Academy, its Commissioners, Officers, Agents, or Employees and the State of Connecticut, its Commissioners, Officers, Agents, or Employees and that the CT Chapter of the IAAI, its Officers, Agents, or Employees, shall not be liable for any injuries or death sustained during such training.

____________________________________________ _________________________ SIGNATURE OF APPLICANT DATE I hereby authorize the above applicant to participate in the above course and, therefore, understand that the above mentioned employee will be covered by my department's compensation insurance coverage while participating in such training and that the Connecticut Fire Academy, its Commissioners, Officers, Agents, or Employees and the State of Connecticut, its Commissioners, Officers, Agents, or Employees and that the CT Chapter of the IAAI, its Officers, Agents, or Employees, shall not be liable for any injuries or death sustained during such training. This applicant is considered by my department's standards to be physically and emotionally fit to perform fire investigation evolutions.

____________________________________________ _________________________ SIGNATURE OF SUPERVISOR DATE

Submit Application to: Connecticut State Police Applications will also be accepted by: Fire & Explosion Investigation Unit ATTN: Det. Paul Makuc Fax: (860) 706-5619 Attn: Det. Paul Makuc 269 Maxim Road or scanned and emailed to: Hartford, CT 06114 paul.makuc@ct.gov

RETIREMENT PARTY Friday March 24, 2017

Cocktail Hour 6:00 P.M. Dinner/Ceremony 7:00pm

Please join us as we honor

Battalion Chief Alan Zygmunt

For his 30 years of service with the

Southington Fire Department

This event will be held at

Testa’s Banquet Facility

26 South Center St

Southington, Ct 06489

A sit down style dinner will be served

Beer and wine included

$50 per person

Advance tickets only

Please contact 860-621-3202 ext. 8234

or stop by Fire HQ, 310 North Main Street

before Tuesday March 14, 2017

Fire Training School Torrington Burrville State Fire School

P. O. Box 335 Pleasant Valley, CT 06063-0335

Dear Litchfield County and neighboring firefighters;

The rebuilding of the Burrville Fire School is slated to start in the early spring of 2017. The contract for the design/build team has been awarded to PDS Engineering out of Bloomfield. We are meeting with them on a weekly basis to finalize the design. We plan on presenting the final plans and discussing the future of the fire school at the February meeting of the Litchfield County Fire Chiefs Emergency Plan, Inc. The state recently demolished the old facility. Until the new facility is complete we will be running courses at local host departments.

The class schedules are set the spring of 2017. The fire school will be running a Firefighter I course at the Goshen Fire Station and an Exterior Firefighter at the Woodbury Fire Station. This summer we plan on running a Firefighter I and II course that is designed for college students. The spring Firefighter I certification course will be run on Tuesday and Thursday evenings and some weekends. The course will include certification at the Hazardous Materials Awareness and Operational levels. The cost is $1,050 which includes all exam fees, student textbook, and student workbook. The application deadline for Firefighter I is February 8, 2017. The course fee will increase to $1,155 after the deadline. The course schedule is attached.

The Exterior Firefighter course will be running on Tuesday nights and some Saturdays. The cost is $250. The application deadline for Exterior Firefighter is March 3, 2017. The course fee will increase to $275 after the deadline. The course schedule is attached.

On behalf of the school committee and the staff of the Burrville State Fire School I would like to take this opportunity to wish everyone a Merry Christmas and a Safe, Healthy and Happy New Year.

Richard Winn Richard Winn, School Director

richard.t.winn@snet.net (860) 309-4375 (cell phone)www.facebook.com/BurrvilleFireSchool

Burrville Fire School Spring 2017 Exterior Firefighter Course - Woodbury

Date Day Hours Subject 3/18 Saturday 8 Orientation/History/IMS/Safety 3/21 Tuesday 3 Rehab 3/28 Tuesday 3 Fire Behavior/Building Construction 4/1 Saturday 8 4/4 Tuesday 3 Hazmat Awareness

4/11 Tuesday 3 Hazmat Awareness 4/15 Saturday 8 PPE/SCBA 4/18 Tuesday 3 Water Supply 4/25 Tuesday 3 Hose/Streams 4/29 Saturday 8 Ladders 5/2 Tuesday 3 Loss Control

5/13 Saturday 8 JPR 5/16 Tuesday 3 Wildland

Burrville Fire School Spring 2017 Firefighter I Course - Goshen

Date Day Hours Subject 2/21 Tuesday 3 Orientation, Introductions & History 2/23 Thursday 3 Fire Behavior 2/28 Tuesday 3 Building Construction/Inspections 3/2 Thursday 3 NIMS/IMS3/7 Tuesday 3 Response/Size-up, Survival, Rehab 3/9 Thursday 3 PPE/SCBA

3/11 Saturday 8 PPE/SCBA 3/12 Sunday 8 PPE/SCBA 3/14 Tuesday 3 Ropes & Knots 3/16 Thursday 3 Ropes & Knots 3/21 Tuesday 3 Communications/LCD, TFD Stocks Radios 3/23 Thursday 3 Ladders 3/25 Saturday 8 Ladders 3/26 Sunday 8 Ladders 3/28 Tuesday 3 Review Mid Term Exam 3/30 Thursday 3 Fire Cause Determination, Sprinklers etc. 4/4 Tuesday 3 Water Supply 4/6 Thursday 3 Fire Attack & Fire Suppression 4/8 Saturday 8 Hose 4/9 Sunday 8 Hose

4/11 Tuesday 3 Wildland Firefighting 4/13 Thursday 3 Loss Control 4/18 Tuesday 3 Vent/Force Entry Lecture

4/20 Thursday 3 Search & Rescue Lecture 4/22 Saturday 8 Search and Rescue, Loss Control Practicals 4/23 Sunday 8 Forcible Entry/Vent Practicals 4/25 Tuesday 3 Extinguishers Lecture 4/27 Thursday 3 Extinguishers Practical and skills review 5/2 Tuesday 3 JPR’s 5/4 Thursday 3 Vehicle Fires @ CFA 5/6 Saturday 8 Haz-Mat Awareness 5/7 Sunday 8 Structural Live Burn @ CFA 5/9 Tuesday 3 Haz-Mat Ops

5/11 Thursday 3 Haz-Mat Ops 5/16 Tuesday 3 Haz-Mat Ops 5/18 Thursday 3 Metering/Monitoring 5/20 Saturday 8 PPE/Product Control 5/21 Sunday 8 Decon/Rescue 5/23 Tuesday 3 Smart Triage 5/25 Thursday 3 Evidence Preservation/Illicit Drug Labs 5/30 Tuesday 3 Terrorism/WMD 6/1 Thursday 3 FFI/JPR Practical Review 6/6 Tuesday 3 Haz-Mat Practical Review TBD 8 State Practical Skills Exam TBD 3 Written Review/School Written

3 School Graduation 3 State Written Exam

Fire Training School Torrington (Burrville State Fire School)

P.O. Box 335 Pleasant Valley, CT 06063

(Please complete both sides)

Chairman Robert Norton Jr. Director Richard T. Winn Asst. Director John B. Field Jr.

Course Application Name: ______________________________ Date of Application: _____________ _____

Course Name: ______________ Course Fee:

Student ID: _____

(First 3 Initials of last name and last 4 numbers of social security number)

(Example: Joe Smith; SS# 123-45-6789: ID would be SMI-6789)

Home Address: __________________________________________________________

City/Town: ____________________ State: ________ Zip Code: ___________________

Phone: (Home)_______________ (Work)___________ _ ____

(Cell) E-Mail: ______________ ________

Are you at least 18 Years of Age? Yes No

***Firefighter I & II applicants must be at least 18 years of age***

____________________________________ Applicants Signature

As Chief of the _____________________ Fire Department, I hereby authorize the above applicant to participate in the Firefighter I or II program and therefore understand that the above named individual will be covered by my department’s worker’s compensation insurance while participating in such training and that the Burrville State Fire School, its’ officers’, Instructors’, Agents’ or Employees’ shall not be liable for any injuries sustained during such training. The applicant is considered by my department’s standards to be physically and emotionally fit to perform firefighting evolutions without special considerations, and where applicable, to meet the 29 CFR 1910.134 standard for the use of respirators (Self Contained Breathing Apparatus).

_____________________________ __________________

Chief’s Signature Date

__________________ __________________________ Purchase Order # Authorized Billing Signature ***Please include a copy of the medical clearance for Firefighter I and II courses.

Fire Training School Torrington (Burrville State Fire School)

P.O. Box 335 Pleasant Valley, CT 06063

(Please complete both sides)

DOB: Emergency Contact: Phone #: Department Representing: Company/Unit: Town: Circle One: Career Volunteer Date Entered Fire Service: Rank: Fire Chief’s Name: Phone #: Email Address: Training Officer’s Name: Phone #: Email Address: Fire Department Mailing Address: I authorize the Burrville State Fire School to release my training records for the _______________ course in which I am enrolled to . Signed: Dated:

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