The student listed below is an active member of the listed organization 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.

Class
The student listed above has medical clearance to use Self Contained Breathing Apparatus, (SCBA), in accordance with 29 C.F.R. part 1910
The student listed above is authorized to use SCBA and participate in interior /exterior firefighting evolutions
Meets the qualifications and age requirements to attend including all of the necessary prerequisites. Copies of certificates must be brought to first day of class.
Is covered by his/her company’s WORKERS’ COMPENSATION INSURANCE, or is covered by his/her own Health and Medical Insurance while attending any course sponsored by the Bucks County Community College / Lehigh Emergency Services Training Academy.
Will abide by all the rules and regulations established by the Bucks County Community College and the Pennsylvania State Fire Academy.
Will abide by 29 CFR 1910.134 and the Pennsylvania State Fire Academy for being clean-shaven for classes requiring the use of APR or SCBA.
Will be responsible to pay for any tuition and/or fees associated with the course, unless otherwise notified by the sponsoring Organization/Employer that is listed in Section above.
Junior Fire Fighters (age 17 and under) will abide by all regulations under the Pennsylvania Child Labor Laws and will not register for or participate in any class with drills involving live fire or smoke generated by live fire.
The Student has never been convicted of an offense that constitutes the crime of “arson and related offenses” under 18 Pa.C.S §3301 or any similar offense under any Federal or state law. I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief.
The department/student listed above will be subject to a $25 “No Show” fee if the student fails to show for the start of the class without notification to LESTA prior to the beginning of the class. Payment of this fee is due within 30 days of the class end date. The student and department agree to follow LESTA’s no show policy. If initialed (no), then student will not be able to attend this training. (See attached policy)

By signing this form below, you, the student and chief officer, agree to the terms listed above. Registrations will not be processed without the signature of the student and chief officer.