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
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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)

VACCINATION
Hepatitis B
Others: ________________

Date of Training