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RDCST Amateur Radio EmCom Responder Intake Form

Please enter the Information Requested in the appropriate space.
The information gathered on this form will only be used in support of the RRTF and not for any other purpose.


Updated: 06/05/2010a
 Contact Info:   
Amateur Call:
License Class:
Name: (First & Last)
Home Phone No.:
Cell Phone No.: (You may receive alerts via SMS)
Pager No.:
Home Email: (Email you want TF Info sent to)
Winlink Email:
Home Unit Affiliation: (Your EmCom Group)
Were you background checked by your home EmCom Group? Yes  or No
Physical Limitation(s):

 CRF:    Your Communications Resource Function(s): (See Communications Resource Functions Guide for descriptions.)
  CRF S CRF B CRF M CRF DMw CRF DA CRF DT CRF H CRF DH
  Additional Communication Modes:     IRLP   Echolink     In vehicle APRS Tracker     Portable APRS Tracker
 

 NIMS:    NIMS ICS courses completed:
  ICS-100 ICS-200 ICS-300 ICS-700 ICS-800 ICS-802 ICS-250 ICS-703
  NOTE: IS courses 100 and 700 are required and 200 is requested before deployment.
 

 EmCom:    ARRL EmCom courses completed:   ECC1 ECC2 ECC3 EC-016   
  Participated in Public Service Events
  Enter additional EmCom training;
  
 NOTE: ECC1 should be completed by all team members.
 

 First Aid:    First Aid Courses:  Basic First Aid   CPR EMT
 

 Response:    Response Availability:   Any Time Can Arrange Schedule Vacation
  Enter Your Maximun Response Availability    (Days)
  Response Type:   Initial Response and/or Reserve Response
  Are you willing to participate in pre deployment training? Yes  or No
  Are you willing to help with other tasks during deployment? Yes  or No
 

 Emergency Contact Info:   
Contact Name:
Phone No.:
Relationship:

 Vehicle Information: 
Make:
Model:
License No.:
Color:

Enter any additional Information;

This form does not work with some web based email clients. If this is the case, just copy the results that come up and paste them in your normal email client and send it to N5TIM(at)sbcglobal(dot)net.


Send comments or suggestions to:
John Galvin, n5tim@arrl.net

Last Modified 10.27.2010 - 02.28.2012