2019 Field Ops - Community Registration
May 4th, 2019
Barton Community College - 245 NE 30 Rd - Great Bend, KS 67530
Barton Field Operation's Day Example
Each participant or observer must complete the following registration form. This information helps us in determining your role in our event. Please provide specific details when applicable.
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Phone Number: *
Your answer
Mailing Address
Your answer
Age *
Your answer
Gender *
If under 18 years of age - Guardian Information
First & Last Name
Your answer
Phone Number
Your answer
Additional Phone Number
Your answer
Emergency Contact Information
First & Last Name *
Your answer
Phone Number *
Your answer
Additional Phone Number
Your answer
Time Available to Attend/Participate: *
If not available for time slots listed, please indicate availability below.
Are you wanting to: *
On a scale of 1-5 rate your acting abilities. *
Please note your ranking will help us place you into the appropriate roles desired.
Are you able to cry? *
Any limitations or restrictions? (pregnant, recent surgeries, physical restrictions, etc.) *
Your answer
Any allergies to latex, tape/adhesive, makeup or moulage? *
During a scenario where Law Enforcement/Criminal Justice is involved, would you be willing to be handcuffed or any other police tactics that would be necessary? *
Are you willing to allow a Barton student to do any of the following techniques? Check all that apply: *
Participants may only receive a total of 3 sticks maximum for the entire day.
Required
Barton Community College - Multimedia Release
I hereby give Barton Community College and its staff permission to publish, copyright and use pictures and/or video of me in which I may be included in whole or in part, composite or retouched in character or form. This media may be used for public relations in the forms of print and web formats.If the person photographed is under the age of 18, I certify that I am his/her parent or legal guardian and I give consent without reservation to the foregoing on his or her behalf. *
Barton Community College - Release of Liability
I understand I am volunteering to participate in the Barton Community College EMS Education Field Operation’s Day scenarios on May 4, 2019. This may include a role as a patient or bystander as deemed necessary by the event coordinator(s).I acknowledge that (to fully train students) the scenarios are meant to be as realistic as possible and my clothes may be stained and/or cut in the process.I also declare (that although no patient will intentionally be put in a dangerous situation and safety will be closely monitored by certified/trained technicians); should an accident/injury occur I will not hold Barton Community College responsible. *
Required
Participant/Observer Authorization Signature
*
To complete your signature, add today's date *
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Questions, Comments or Concerns:
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