Name:*

Title*

Organization:*

Mailing Address*

Email Address:

Date:*

Phone Number:*

Class Title:*

Class Size:*

Length in Hours:

Date(s) Requested:*

Start Time:*

End Time:*

Instructor:*

Safety Officer:

*

Areas Requested:

(Choices)

Classroom Maze Building Sprinkler Prop Extrication Pad Lunch Room (usually shared by all occupants) Garage (will hold approximately 100 seated people) Burn Building - Specific Orientation Required Gas Prop - Specific Orientation Required

Tower 1st Floor Tower 2nd Floor Tower 3rd Floor Tower 4th Floor Tower 5th Floor Entire Tower Building Exterior of Tower Pond

Does your class involve:

(Choose all that apply)

Fire Evolutions Gas Evolutions Explosives

Rappelling Vehicle Extrication None of the Above

Any other hazardous activity? If so, please specify: (PLEASE NOTE - IF YOUR CLASS INVOLVES ONE OF THE ABOVE, A LESSON PLAN MUST BE ATTACHED)

Hazardous Activity:

IF YOU ARE NOT A FREDERICK COUNTY AGENCY, A CERTIFICATE OR PROOF OF INSURANCE AND COURSE OUTLINE MUST BE PROVIDED PRIOR TO USE OF ANY AREA IN WHICH PHYSICAL ACTIVITY MAY CAUSE INJURY.

Please note that, in addition to an initial orientation, each agency is responsible for:

(1) Opening and securing the Facility (if no staff is available)
(2) Their own office supplies and equipment
(3) Making sure students are aware of designated smoking areas
(4) Returning the area of use to it's original state
(5) Reporting any problems by calling 301-600-2282
(6) Scheduling and returning any keys to Mary Baker. Key return shall be within 48 hours.

If you cancel a class, please notify us ASAP. This form should be submitted as far in advance as possible.

Fax to: 301-600-2284

Email to: mbaker@frederickcountymd.gov

Additional Comments: