/ Black Diamond Search and Rescue Council
Application and Background Investigation Authorization Form / Page 1 of 4
06-28-2013

By completing this application I acknowledge that membership in the Black Diamond Search and Rescue Council represents the privilge of service to the citizens of virginia. This privilege may be revoked or suspended for violation of law, or as a result of behavior that may reflect unfavorably upon the Council.

Please Print ~ All spaces must be completely filled out before membership can be considered.

Applicant Information

Applicant’s Legal Last Name / Applicant’s Legal First Name / MI / DMV or Government ID Card Number
MM / DD / YYYY
Race / Gender / Hair Color / Eye Color / Height / Weight / Date of Birth / Place of Birth
County or City and State

Your Current Mailing Address

/

Callout Information

Street Address
City or Town of Residence / State / Zip
E-mail Address:
PLEASE NOTE: we do not contact individuals through US Postal Service – we use email as our primary form of contact.
Emergency Contact Information
Street Address
City or Town of Residence
Telephone Number
/ Home Telephone Number
Work Telephone Number
Text Paging Address
Cellular Telephone Number and Cell Provider
Pager Number
Alternate Telephone Number
PLEASE NOTE: These numbers will be entered into our CallOut system unless otherwise specified. If you do not want your work phone or home phone to receive callout notices, please let us know.
Equipment Color Code/Marking

Vehicle Information

Make / Model / Year / Plate Number
Make / Model / Year / Plate Number

Applicant’ Personal Information

Applicant’s Legal Last Name Applicant’s First Name

Please List Training and Experience

Search and Rescue Certification and Date of Completion

FTM
FTL /
FTS /
MSO /
PSO /
ICG /
WRT /
Other /

Medical Training

First Aid
CPR /
EMT
(List Level) /
RN /
MD /
Independent
Practiconer /
Other /

Mission Experience

Day Search
Night Search /
Winter Search /
Search Management /
Semi-Technical Rescue /
Vertical/Technical Rescue /
Cave Rescue /
Other /

Please List Other Experience, and Any Other SAR Organizations to Which You Belong

Applicant Information

Applicant’s Legal Last Name Applicant’s First Name
Conditions
Indicate below if you been convicted or found guilty of any crime, offense, or regulatory violation, or whether you havew participated in other prohibited conduct identified by Virginia Office of Emergency Services regulations
Yes No have you been convicted or found guilty of any crime involving sexual misconduct where the lack of affirmative consent by the victim is an element of the crime, such as forcible rape?
Yes No have you been convicted of a felony involving the sexual or physical abuse of children, the elderly or infirm, such as sexual misconduct with a child, making or distributing child pornography, or using a child in a sexual display, incest involving a child, or assault on an elderly or infirm person?
Yes No have you been convicted or found guilty of any crime (including abuse, neglect, theft from or financial exploitation of a person entrusted to your care or protection) in whch the victim is a patient or resident of a health care facility?
Yes No have you been convicted or found guilty of any other act that is a felony? (except that a felon is eligible for consideration five years after the date of final release if no additional felonies have been committed during that time).
Yes No are you under any disciplinary or enforcement action from any state EMS office or other recognized state or national health care or search and rescue licensing or certifying body? (persons subject to these disciplinary or enforcement actions may be eligible for consideration providing there have been no further disciplinary or enforcement actions for five years prior to application to the Black Diamond Search and rescue council).
Yes no have you been subject to a permanent revocation of license or certification by any state EMS office or other recognized state or national heathcare or SAR licensing or certifying body?
Yes No I understand that any references to criminal acts or convictions under this section of the application refers to substantially similar laws or regulations of any other state or terratory ot the United States. Convictions include prior adult convictions, juvenile convictions, and adjudications of delinquency based on an offense that would have been, at the time, a felony conviction if committed by an adult within or outside of virginia.
Yes no i understand that i may not be under the influenceof any drugs or intoxicating substances that impair my ability to provide patient care or operate any motor vehicle while involved in any training, mission, or public activity of the black diamond search and rescue council, inc.
Yes no i understand that i must complete interactive on-line Incident Command System and National Incident Command system training to be eligible to participate independantly in training, mission, or public activities of the black diamond search and rescue council, inc. (Print out and Attach copies of certificates of competion of the courses listed below).
Yes no i understand that i must assemble a search pack with personal survival suplies and first aid supplies and develop the skills and experience required to safely use them in order to be eligible to participate independantly in training, mission, or public activities of the black diamond search and rescue council, inc.
Applicant Information
Applicant’s Legal Last Name Applicant’s First Name
Yes No i authorize the black diamond search and rescue council, inc. to conduct a Virginia Criminal Information Network (VCIN) records check.

I certify that the information I have given is true and correct. I understand that providing false information on this form is grounds for denying membership in the Black Diamond Search and Rescue Council, Inc.

I have read and understand the above statements.

Applicant’s Signature / Date
Printed Name
Witness Signature / Date
Printed Name

Membership Committee Action

Approve Application for Membership:
Yes No
Date
Comments
Signature
Signature

Training Available from the Federal Emergency Management Agency:

http://emilms.fema.gov/IS100A/index.htm IS-100.a Introduction to Incident Command System

http://training.fema.gov/EMILMS/IS200A/index.htm IS-200.a ICS for Single Resources and Initial Action Incidents

http://emilms.fema.gov/IS700aNEW/index.htm IS-700.A National Incident Management System (NIMS), An Introduction

http://emilms.fema.gov/IS800B/index.htm IS-800.B National Response Framework, An Introduction

http://emilms.fema.gov/IS809/index.htm IS-809 ESF#9 Search and Rescue

Revision Date 06-28-2013