Please print all information                                          Date: _______________

I. General Information

Name (First, M.I., Last): ________________________________________________________________

Date of Birth: ________________     Gender: _____ M _____ F

Home Address: ______________________________________________________________________

City/State/Zip code: ___________________________________________________________________

Home (____) _____-______ Cellular (____) ______-_______ Service Provider: ____________________

Pager (____) _____-______ Fax: (_____) _______-________

Email: ___________________@_______________________

Name of Subdivision (neighborhood): ____________________________________________________

Emergency Contact Person and Telephone number: ________________________________________

__________________________________________________________________________________

Language fluency (other than English): ___________________________________________________

Do you have any physical limitations or medical conditions) requiring special accommodations? ______

If yes, please explain: ________________________________________________________________

Do you have children or family members that would need care in the event that you are called to assist? ___Yes ___No

Do you own: (circle any that apply)   4-wheel drive vehicle    motorcycle   4-wheeler   boat   Other:_____________________________________________________________________________

Have you had the hepatitis B vaccine series? ______________________________________________

How did you find out about our CERT Program? ____________________________________________

 

II. Work Related Information

Full time: ___ Part time: ____ Retired: ___ Not currently working: ____

Employer:___________________________________________________________________________

Work Title: __________________________________________________________________________

Address: ____________________________________________________________________________

City/State/Zip: _______________________________________________________________________

May we call you at work? _____Yes _____ No

Work phone: (___) ____-_______ ext. _______ Fax: (____) _____-_________

Work Related Certifications/Skills: (please list any you may have and expiration dates if applicable)

___________________________________________________________________________________

 

III. Skills & Experience

Special Skills/Experience (machine/equipment/clerical/childcare/teacher/military/ministry/disaster survivor, business, computers, homemaker etc):

____________________________________________________________________________________________________________________________________________________________

 

Have you received training in: (Circle any that apply)

First Aid                                   Search & Rescue                   Documentation/Records

CPR                                        Disaster Preparedness          Law Enforcement

Incident Command                 Weather Emergencies           Amateur Radio

Team Building                         Wilderness Survival                Crime Watch

Crisis Intervention                   Damage Assessment             Hazardous Materials

Fire Suppression                    Am. Red Cross Vol.                Other:_________________________________

                       

Are you CPR certified? ___Yes ___ No  If yes, certificate expiration date: ___________

Are you AED certified? ___ Yes ___No  If yes, certificate expiration date: ___________

IV.  Background Check:

 

I, ___________________________________, give permission to the Medical Response Team Planning Committee to have the Versailles Police Department do a criminal background check on me. I understand that an unsatisfactory Background Check will result in ineligibility for the team.

 

Social Security Number: ___________________________

 

Signature: _______________________________________ Date: _____________

 

Official Use Only Prepared by: __________________________ Date: ________________________ Comments:

 

V. Pictures

 

Photos may be taken during the training classes. These may be used in the MRC Newsletter, for recruitment purposes or on the website. Your signature gives us permission to use any photo you may be in for this purpose.

 

Signature: ________________________________________

 

VI. Medical Background  (To be completed if you have a health or medical background)

 

Physician:

Board Certified: _____ Yes _____No             Area of Specialty: _______________________

 

Nurse:

_____ RN            LPN_____                           Area of Specialty: _______________________

Emergency Medical:

_____ First Responder_____ Paramedic_____ EMT

 

 

Other Medical Backgrounds:

_____ Veterinarian

_____ Pharmacist

_____ Mental Health Practitioner

_____ Psychologist

_____ Social Worker

_____ PA

_____ ARNP
_____ Phlebotomist

_____ Optometrist

_____ Dentist

_____ Environmental Health

_____ Health Educator

_____ Med Tech

_____ Nurse’s Aide

_____ Clinical Assistant

_____ Respiratory Therapist

_____ Radiologist