Hornbeck Search and Rescue Team - Missouri / Illinois

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MEMBERSHIP APPLICATION FORM

The Hornbeck Search and Rescue Team is always looking for new members to help us continue our mission of helping others in times of need. If you would like to become a part of our team you will first need to fill out the below form and submit it. After the form is submitted you will be contacted by a team representative and invited to join us at an upcoming training session where you can meet the other members of the team and continue your application process.

The Hornbeck Search and Rescue Team does not determine member eligibility based on sex, race, creed, persuasion and or religion. Due to liability laws we requre that all applicants MUST be a minimum of eighteen (18) years old and have received no dishonorable discharges from military service and/or must not have been convicted of a felony. A background check will be performed prior to you becoming a full status member of the team are are a part of the application fees.

Applicants must be physically capable of performing the activities for which they are applying. Your application will be reviewed and you will be contacted with further information concerning the specific areas for which you are seeking membership.

ALL FIELDS ARE REQUIRED UNLESS NOTED IN TAN.

Please provide the following Contact Information:

First Name:
Last Name:
Title:
Street Address:
Address (cont.):
City:
State:
Zip Code:
Work Phone:
Home Phone:
FAX:
Cell Phone:
E-mail:



Postal Address (If different from physical address):

Postal Address:
City:
State:
Zip Code:



Please Identify and Describe Yourself:

Date of Birth:
Sex:	Male Female
Height:
Weight:
Employer:
Occupation:
Driver's Licence No:
Expires:	-- mm/dd/yy



Next of Kin / Emergency Contact:

Name:
Relationship:
Address:
City:
State:
Work Phone:
Home Phone:



Medial Information/History: ( This information will remain HIGHLY confidential )

How would you describe your current health?

How would you describe your current physical condition?

List any allergies or medications you are currently taking:

Blood Type:

Do you now have or have you had any serious medical condition? Yes No

Have you been hospitalized in the past year? Yes No

Do you have any other medical or health condition which might adversely affect you in the field? Yes No

If Yes, please select one of the following options that may apply: Physical Visual

Are you Color Blind? Yes No



SAR Experience and Training: ( Check any areas in which you have had any Experience and or Training )

4x4 Driving Operation
Flying (as a pilot)
Search and Rescue
Abseiling
Incident Command
Search Dogs
Backpacking/Hiking
Interview Skills
Horseback Riding
Search Fundamentals

Caving
Land Navigation/Compass
Search Management
Cave Rescue
Law Enforcement
Survival
CISD
Map Reading
Swift Water Rescue

Communications
Public Information/Relations
Tracking
Disaster Response
Rope Rescue, Basic
Other (please specify)
Firefighting
Rope Rescue, Hi-Angle
ATV Operations




Medical Training/Background: ( Please identify your current medical certification level, training, or experience, if any )

CERTIFICATION	TYPE / LEVEL	CERT. NO.	EXPIRES
FIRST AID
CPR
BAA (Level 5)
AEA (Level 6)
MD, RN (Level 7>)

Please describe your experience in Medical Services:




Your Call-Out Response Information:

Would you be able to respond to a call in the middle of the night? Yes No

Does your family understand the conditions of this application and call-out possibilities? Yes No

Do you understand that calls may come at various times of day or night, 7 days a week? Yes No

Do you understand that if at all possible you would be EXPECTED to respond to ALL callouts (except for family and work emergencies)? Yes No

Do you understand that, once accepted as a member, you will be expected to attend training and exercises on a regular basis? Yes No

Since we are an Emergency Response Team, do you have any other emergency-response commitments that might create a conflict? Yes No

If you would possibly have a conflict, please explain below:




I am interested in assisting with the following sections of the team: ( You may select more than one )

Command Center Operations - Administration/Communications/Mapping/Incident Management/Transportation
Search & Rescue - Search Management/Ground Search Operations/Ground Rescue Operations/Search & Rescue Training
K-9 Search & Rescue - K-9 Search Management/K-9 Search Operations/K-9 Training
Dive Team - Dive Operations
Search Support Services - Logistical Services/Administrative Functions/Meal Preparation

PRINT THIS PAGE BEFORE CLICKING THE SUBMIT BUTTON BELOW!

Please note that The Hornbeck Search and Resuce Team is a volunteer organization and there will be times when it will not be possible for all personnel to respond to a callout. While you are expected to respond whenever possible, no action is taken against members who are only able to make a reasonable percentage of training and callouts due to work or family emergencies.

The demands of family and career are very well understood and respected by the team. Excessive absences from the team for trainings or callouts may result in removal from the team.

(Please complete section below after printing and bring it with you when you attend your first training session!)

THE HORNBECK SEARCH AND RESCUE TEAM

I ___________________________________ , am aware that while a member of The Hornbeck Search and Rescue Team, (also known as HSAR), I may be participating in and responding to activities that are inherently dangerous, including, but not limited to, the hazards of traveling in wilderness terrain, accidents or illness, the forces of nature and travel by automobile, aircraft or other conveyance. I understand that, except when otherwise provided, insurance, workman's compensation, and liability coverage is not provided and that I am solely responsible for any injury, illness, or other medical care required by myself while participating as a member on HSAR activities.

I agree to maintain the minimum insurance required by law in my home state, on my personal vehicle if I choose to drive it on Hornbeck Search and Rescue activities and that I will be responsible for any and all damage to my vehicle and other property while on Shawn Hornbeck Search and Rescue activities. I do these things entirely on my own initiative, risk, and responsibility, and assert that I will do nothing that is beyond my training and expertise. In consideration of the benefits to be derived, I do hereby for myself, my heirs, executors, and administrators, release and forever discharge Hornbeck Search and Rescue Team and/or the Shawn Hornbeck Foundation, its directors, members, officers, and agents, from any and all claims, demands, actions, or causes of action, on account of my death or injury, or for damage to my personal property, as a result of my participation in Hornbeck Search and Rescue Team activities.

I understand that if I do not feel comfortable or competent in a given situation, it is solely my responsibility to ensure that I stop the activity immediately and in a safe manner. I hereby agree to abide by all rules, regulations, policies, and procedures prescribed for in the subscription to Shawn Hornbeck Search and Rescue Team and I understand that I may be terminated from said subscription for any cause, at any time, upon written notice to myself, mailed to me at the address given on this application for subscription.

I understand that I may voluntarily terminate my membership to Hornbeck Search and Rescue Team at any time upon written notice mailed to the organization's usual mailing address, or delivered to any director of the organization, by any means. I understand that, in order to maintain an active membership, I must keep Hornbeck Search and Rescue Team appraised of any changes in name, mailing address, or telephone number, etc and pay any subscription and/or radio fees prescribed.

I desire to become an active member to Hornbeck Search and Rescue Team. I agree to attend the required number of training lectures / classes to establish and maintain my ability as a competent subscriber of this organization and to acquaint myself with the duties and other members of Hornbeck Search and Rescue Team. I have read and understand the requirements of this application to become a subscriber to this organization, and promise to abide by and adhere to the Procedures, by-laws and all operational rules and regulations as set forth by Hornbeck Search and Rescue Team to the best of my ability. Additionally, I attest that all the information provided by me on this application is true and correct to the best of my knowledge, acknowledging that providing false or fictitious information may result in my immediate dismissal from the organization upon discovery of such.

I UNDERSTAND AND FULLY AGREE TO THE ABOVE:

SIGNED AT : ____________________________________________________

DATE : __________________________________

INTRODUCED BY : _______________________________________________

APPLICANT'S SIGNATURE : _______________________________________

WITNESS : ______________________________________________________

Please sign the section above and bring it with you to the first training event that you attend with the Hornbeck Search and Rescue Team. Failure to turn in this application will delay your starting date for your initial probationary period with the team. Please also include the following with your application:

Joining/Subscription Fee of $40.00
( Fees will be used for a Missouri State Highway Patrol Background Check, Application Processing and a T-Shirt )

Copy of: 2x Photo I.D.'s or 1 Photo I.D. and 1 other official I.D. source

I verify that the above information is correct and know that the Hornbeck Search and Rescue Team may issue a background check to verify the above information that is being submitted for accuracy.