Upper Hutt Community Rescue

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Basic Rescue Course

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Basic Rescue Course Details

Basic Rescue Course what is it?
A course designed to train people to get the skills required to assist others in the time of a major disaster.

The course is made up of the following elements;

Civil Defence organisation in NZ.
Personal safety.
Casualty assessment.
Casualty movement.
Working with stretchers
Building reconnaissance
Equipment training.

What are the course dates?
Next course starts on: 6^th June 2009
Registrations must be received no later than 30^thMay 2009.

What to do next? ...
Complete the enrolment form below to ensure that you are accepted on the next course, do not miss out enrol today. Full details will be sent out to you. So an email or street address is important.

Basic Resue Enrolment Form
Complete all the boxes and click the Send button.

Enter your details here :-

*First Name:

*Last Name:

Preferred Name:

*Number & Street:

Address:

Suburb:

*City:

Country:

Contacts:

Format:(Area Code) Number 3+4 eg:(04)123 4567
		Prefered Contact Method
Phone		Check One
Fax		Check One
Mobile		Check One
*E-Mail		Check One

Occupation:

Your Interests:

Select one or more options by using the CTRL key.

Personal Details:

*Gender Male Female

*Date of Birth: (DD/MM/YYYY)

Medical Details:

General Health
Appendix Removed
Tonsils Removed
Organ Donor

Date last Tetanus: (DD/MM/YYYY)

Known Conditions
Asthma	Diabetes
Epilepsy	Angina
Migraines	Hay Fever
Haemophiliac	GI Bleeds
High Blood Preasure	Severe allergic reactions

Other - specify
Heart Conditions - specify
I am currently on medication Check for Yes
If YES then provide
Dose
Frequency
Side Effects

Known Phobias
Fear of Heights	Fear of Confined Spaces
Fear of Open Spaces	Fear of Dark
Fear of Insects	Fear of Water
Fear of Fire	Other
If Other - specify

Medical Disclosure:

The medical information provided is to the best of my knowledge accurate and current as of this date. I undertake to notify in a timely manner any changes to these details, as I am aware that this may impact on my eligibility and ability to perform my training and duties within the team.

Agree Disagree
Check one of the boxes.

*Participation Disclosure:

I accept that my participation in the activities as a voluntary member of Upper Hutt Community Rescue while training or assisting during a Civil Defence emergency will involve some risk due to the unpredictable force of nature or surroundings. I accept the team leader or person designated in charge of activities has the overall responsibility of managing safety of the activities or tasks I take part in, and I will follow all reasonable instructions given to me, that ultimately I am responsible for my own safety. I also accept that if I choose to act outside the directions given to me by those in charge, I will retire from the activity immediately when requested and be personally responsible for my own safety thereafter.

Agree Disagree
Check one of the boxes.

Confidentiality:

Information supplied for course registrations is subject to the Privacy Act 1993 and remains between the applicant and provider. Consent of the release of all or any part of the information held must be given in writing to the provider.

Identity Security:

Enter below image letters here

Finished

* Are required fields

Please ensure that all the required information is completed, as incomplete forms may result in a delay getting an allocated space on the course. Spaces are limited and allocated on a first come first served basis.

"Join the ultimate emergency service"

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Learn to help your fellow man by being prepared yourself, you never know when you will need it!.

Downloads
BR Course Registration in PDF form. BR Course Registration in Word Doc form.

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