Rescue International

Rescue International

PO Box 544 Delaware Water Gap, PA 18327

Fax 877-539-4686

E-mail: director@rescueinternational.org

Application - Response Team Member
Recovery Task Force Member

Personal Information

Name(Last )________________________________ First _____________________ MI ________

Street _________________________________________________________________________

City ____________________________________________ State __________ Zip ____________

Country ____________

Date of Birth _______________________ SS # ____________________________

Height ___________ Weight ___________

Medical Conditions ______________________________________________________________

_____________________________________________________________________________

Medications ___________________________________________________________________

Doctors Name ___________________________________ Phone _________________________

Contact Information

Home Phone____________________________________________________________________

Mobile/PCS #_________________________e-mail_____________________________________

Pager #______________________________e-mail_____________________________________

FAX _________________________________________________________________________

E-Mail ________________________________________________________________________

Employment Information

Company Name ________________________________________________________________

Phone #_____ ________________________________________________________________

Can you be called at work for emergencies. Y ____ N ____

Please note that an e-mail address and a Nextel digital phone will be required by all members to be an active disaster response team member. Recovery task force members must have a cell phone with messaging BUT a Nextel is recommended. Do not get a NEXTEL till you have been accepted and know the requirements of the phones we use.

Next Of Kin Emergency Contact Information

Name _______________________________________ Relation __________________________

Phone # ______________________________________________________________________

SAR Emergency Services Experience/Training

Check one item for your Primary and Secondary SAR specialty for joining RI.

Primary: Management __ Communications __ Light Rescue __ Search __ Canine __ Separate application required for the K9

Relief Operations __ Man tracking __ Water rescue/flood operations __ Medical __ Logistics ___

Other : ______________________________________________________________________

Secondary: Management __ Canine __ Communications ___ Light Rescue ___ Logistics ___

Relief Operations __ Man tracking __ Medical __ Pet Rescue __ CISM __Search __

Other : ______________________________________________________________________

What is your general interest in joining Rescue International : ____________________________________________________________________________

____________________________________________________________________________

Medical Training / All members must have minimum First Aid and CPR or higher training.

___________________________________________________ Exp: ___________

Other Training / Attach additional pages with copies of certificates as needed.

___________________________________________________ Exp: ___________

Do you have any degrees or professional expertise: Yes ___ No ____

If yes, explain________________________________________________________________

__________________________________________________________________________

Are you a member of any other team, department or emergency service agency:

Yes___ No___

Name: _____________________________________________________________________

Address ____________________________________________________________________

City _________________________ State _____ Zip _____ Phone _______________________

Name: ______________________________________________________________________

Address _____________________________________________________________________

City _________________________ State _____ Zip _____ Phone _______________________

Are you willing to travel: Nationwide _____ International _____

Agreement and Signature

I, the below signed applicant, agree that I volunteer my services to Rescue International without pay or compensation. I also agree that I will hold Rescue International, it's officers and members harmless for any loss of life, limb or damage that may arise as a result of my participation with Rescue International. It is understood that as a member of Rescue International's Special Emergencies Response Team it is not guaranteed that I will be deployed to any emergency responses, disasters or other activations with Rescue International. I also agree that I will not represent myself or my canine to any person or agency in Rescue International's name without RI's approval per the SERT's SOP's, nor will I respond to any emergency, search operation or any other operation as Rescue International without RI's approval or request.

Mail completed application to the above address.

Signature of Applicant ___________________________________________Date:____________

Received By: _____________ Date Received: _______________ Member Number ___________