Timmins Porcupine Search & Rescue Inc.

Membership Application

Applicant Information

Last Name / First / Date
Street Address
City / Province / Postal Code
Home Phone / E-mail Address
Work Phone / Other contact number
Date of Birth
Emergency Contact: Phone: Relationship:

Certifications

Driver’s License / Class / License number
First Aid / Level / Expiry Date
CPR / Level / Expiry Date
EFR / EMR / Level / Expiry Date
OSARVA / Level / Expiry Date
Other / Level / Expiry Date
Other / Level / Expiry Date
List other qualifications, certificates, radio licenses. (i.e.) Paramedic, Nurse, Instructor.

Questions

ò  Are you willing to undergo a background check? / YES £ NO £
ò  Are you willing to undergo a yearly medical? / YES NO £
ò  Are you willing to participate in ongoing mandatory search & rescue training standards as prescribed by the units training committee? / YES £ NO £
ò  Are you willing to participate in unit committee functions? / YES £ NO £
ò  Are you physically fit and able to carry out search & rescue activities? / YES £ NO £
ò  Are you bondable? / YES £ NO £
ò  Do you understand the nature of our work and are you prepared to accept the risks of rescue work? / YES £ NO £
ò  Have you had any formal training in search and rescue techniques? / YES £ NO £
If yes explain
ò  Do you have you any post-secondary education? / YES £ NO £
If yes explain
ò  List reasons why you feel you would be of benefit to our search and rescue unit.
ò  Photo Consent Waiver
I consent to the use of my name, portrait, picture or photograph in as part of Timmins-Porcupine Search and Rescue Inc. image bank. This is a collection of images of Volunteers in work and training situations, intended to showcase the Organization’s activities.
The images in this collection will be used on the Timmins-Porcupine Search and Rescue Inc. website (www.tpsar.ca), for ID badges as well as in publications and marketing products such as displays, pamphlets and presentations. I understand that my name, portrait, picture or photograph will be included in this image bank. I agree that I shall have no claim against Timmins-Porcupine Search and Rescue Inc. or against anyone accessing or using images as part of this collection.
I confirm that I am over 18 years of age, and that I have not given anyone the exclusive right to use my name, portrait, picture or photograph.
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
Signature Date
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