NATIONAL DISASTER RESPONSE TEAM "VITA PRIMORIS" Search and Rescue Disaster Relief Rehab / Canteen Volunteer Application Section 1: Personnal Information Name:Last__________________________First________________________Middle____________________ Current Address:_________________________________________________________City_____________________ State_____________________ Zip_______________________ Mailing Address:_________________________________________________________City_____________________ State_____________________ Zip_______________________ E-Mail address (If Applicable):___________________________________________________________ Contact Number:__________________________ Alternate Contact Number:_______________________ Date of Birth:___________________________ Driver’s License Number:________________________ State:_______ Expiration:________ Class:__________ Section 2: Back Ground Check: Have you ever been convicted of any crime or received a major traffic citation? Yes:_____ No:_____ (If you answer yes,complete the following): Date of conviction, Nature of conviction, Any Parole or Prabation if currently served. *Initials_______ I give authorization for myself or the applicant: as Parent or Guardian, to be finger printed for purposes of a back ground check and do hereby authorize release of such information to the President and/or Regional Director(s) of the NDRT for determination of eligability only. Sex Offenders / Drug Offenders / Crimes of Violence or Hate Crimes are not eligable to apply. Faulsification of this information will be given to Local Law Enforcement for investigation. Section 3: Personnal Work History Employer:________________________________________________________________________________ Employer Phone:_____________________________ Would your Employer allow you time off for deployment to a disaster or Search and Rescue mission? Yes:_____ No:_____ Section 4: Medical Information Emergency Contact:___________________________________________ Relationship_______________ Day Phone ________________________ Evening Phone_____________________ Family Physician (Full Name)_____________________________________________________________ Day Phone ________________________ Evening Phone_____________________ NOTE: Please list any physical or mental condition(s) that might effected yourself or others in the event of or while working under normal or adverse conditions. Such condition(s) would not automatically disqualify the applicant (However failure of disclosure will be deemed as faulsification of information, and can be grounds for dismissal and/or other disciplanary actions). This information is deemed vital so that appropriate personnel have contingencies plans established should these conditions occur during a deployment or SAR mission. List any medical conditions:_____________________________________________________________ _________________________________________________________________________________________ Allergies:_______________________________________________________________________________ blood type:________________________________________ MEDICAL TREATMENT PERMISSION RELEASE: I give my permission to be treated by any qualified medical physician or facility in the event of an emergency. Name:________________________________________Signature: _________________________________ Parent / Guardian Signature (if under 21 years of age)Date:______________________________ Working Environment Possibly Encountered: Rough terrain, inhospitable weather, insects, plants, animals, reptiles, fumes, long hours, tedious necessary tasks, dealing with people and their various moods, climbing rock walls/cliffs, confined spaces, heights, searching for remains or bodies of people, and/or other situations or environments that could be found in emergency/disaster situations. *Initials_______ I have read and understand that these conditions are apart of or can be apart of the Job: (ATTENTION: Parent or Guardian, if applicant is under 21 years of age: I am aware of my son(s) and/or daughter(s) affiliation with the NDRT and that there will be times when they may encounter some or many of the conditions listed in above and give my consent for participation) *Initials_______ I hereby certify that the information provided in my application is freely given, true, and complete. I understand that any false statements, answers, or any misleading information may be sufficient grounds for immediate disqualification or dismissal at any time. *Initials_______ I authorize my employer, references and anyone contacted by the NDRT herein to release requested information about me in reference to the job/position that I will be performing including my ability to interact with others. *Initials_______ I hereby release the NDRT from any liability, damages, or legal action which may result from any action(s) I do that are outside the Policies,or guide lines set forth by the NDRT. Name:________________________________________Signature: _________________________________ Parent / Guardian Signature (if under 21 years of age)Date:______________________________ Section 5: Skills Information I am interested in or have experience in the following: o Air Searching o Amphibious/Boat Searching o Dive Rescue o Dog Team o Ground Searching o Medical Team o Motorized (ATV) Rescue o Mounted Rescue o Mountain Rescue o Support Group I have the following type of equipment: Airplane (type): __________________________________ Boat (type): ______________________________________ Diving Gear: ______________________________________ 4x4 Vehicle (type): _______________________________ Radios (type): ____________________________________ Horse (type): _____________________________________ ATV (type): _______________________________________ List outdoor experience or equipment owned not listed above as well as List any certificates, licenses and/or qualifications held that may be beneficial to the position you are applying for and the NDRT: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Remarks: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ For policies of the Organization on this subject, Please visit our Policy Page. Mail application to: National Disaster Response Team National Headquarters Attn: Applications P.O. Box 1118 Wetumpka, Alabama 3609