Per pluvial aut tempestas, tua vocant nos Videte, in tua hora opus
Poblacion, Tuba, Benguet, Philippines
(074) 420 9005 / +63999 727 5554 / EMS_tuba@mail.com Application Form, Series of 2014 THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED EMERGENCY MEDICAL SERVICES Project Polaris-i
Triage/Treatment/Transport Training Application Form Fill the appropriate boxes, use CAPITAL letters only Family Name First Name Middle Name Name Adjunct Applicant Number
Sex Address Age Civil Status Email Address Birth Date Contact Numbers Birth Place Height Religion Weight Language Spoken Blood Type Dialect Spoken
Contact Person in Case of Emergency Relationship Contact Number Address
Education Name of School Degree Earned Inclusive Dates Tertiary Post Graduate EMT Course
Organization/Association Type of Involvement Inclusive Dates
I attest that all entries I made herein are true and correct. I authorize __________________________ EMS Tuba & its personnel to investigate these entries. Applicants Signature
Short Answer. How would YOU explain the following sentences? Write your answers at the back of this document. Answers should be in paragraph/s with MORE THAN 100 words each paragraph.
1. Birds of the same feather, flocks together. 2. Silent river, runs deep 3. Who am I? 4. What have you heard of EMS - Tuba - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Training Fee Payment Details (to be filled by receiving EMS personnel)
Full / Installment Amount Received by Signature Date
Total Batch Are you aware that you will not get paid for your services in this organization? Yes No
Do you have any illnesses or problems that may hinder the training &/ duty? Allergy Health
How did you find out about this organization / training? Friends Newspaper Facebook Others ________________
Attach here 1 pc of your recent 2x 2 ID photo.
Photo must be front, facial close-up with white background.
Write your complete name and signature at the back of the photo. Place () marks in all appropriate boxes
COURSES ATTENDED Basic Life Support (BLS) Advance Cardiovascular Life Support (ACLS) Basic First Aid Intravenous Therapy Training (IVT) International Trauma Life Support (ITLS) / Prehospital Trauma Life Support (PHTLS) Water Safety and Rescue Basic Fire Safety & Rescue Basic Search & Rescue (SAR) Rope Works / High Angle Rescue Emergency Medical Responder (EMR) Emergency Medical Technician (EMT)