Surveypoint

I Have Taken a CWS Course in the Past*

YES! (required to become an instructor)

No... (please take a course with us first)

First Name

Full Name*

Last Name

Full Name*

E-mail*

Phone Number

Phone Number:*

Street Address

Mailing Address*

Street Address Line 2

Mailing Address*

City

Mailing Address*

State / Province

Mailing Address*

Q10

Postal / Zip Code

Mailing Address*

Q11

Age:*

Please Select

Q12

Sex*

Please Select

Male

Female

Q16

Race*

Please Select

Asian/Pacific Islander

Black

Indian/Alaskan Native

Unknown/Other

White/Caucasian

Q17

Social Security #:*

Q18

Have you ever been convicted of any misdemeanor or felony?*

Yes

Q19

If yes, please explain:

Q20

Current Certifications:*

CPR/AED - Adult

CPR/AED - Child, Infant

CPR/AED - Healthcare Provider (Professional Level)

Standard First Aid

Lifeguard (Red Cross or Ellis)

Wilderness First Aid (WFA)

First Responder

Wilderness First Responder (WFR)

EMT-B

WEMT

EMT-I

EMT-P

RN/LPN/BSN

Other (specify in comments section)

American Red Cross Instructor

American Heart Association Instructor

Q21

Languages That I'm Fluent In:*

English

Spanish

German

French

Chinese

Japanese

Hindi

Q22

Position(s) Interested*

Instructor -- Wilderness Medicine

Instructor -- American Red Cross

Special Event EMS Team Member (VA, DC, MD only)

Administrative Assistant

Internship

Volunteer & Alumni Coordinator

Q23

Can you work weekdays?*

Yes

Q24

Can you work weekday evenings?*

Yes

Q25

Can you work weekends?*

Yes

Q26

Can you work holidays?*

Yes

Q27

Month

When can you start?*

Q28

Day

When can you start?*

Q29

Year

When can you start?*

Q30

Describe your experience with emergency medical care (if any).*

Q31

Describe your teaching or public speaking background.*

Q32

Give an example of when you exhibited leadership skills in an outdoor environment.*

Q33

Briefly explain your outdoor/wilderness skills & abilities.*

Q34

Do you have any relevant wilderness rescue experience?*

Q35

Why do you wish to become a Center for Wilderness Safety staff member?*

Q36

List all professional organizations that you are affiliated with.*

Q37

Professional Reference (1)*

Q38

Professional Reference (2)*

Q39

Personal Reference:*

Q40

Cover Letter*

Q41

Upload Resume*

Q42

Upload Your Photo*

Q43

Comments or Questions:

Q44

Medical Staff Application Form -Form Fill

I Have Taken a CWS Course in the Past*

First Name

Last Name

E-mail*

Phone Number

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Age:*

Sex*

Race*

Social Security #:*

Have you ever been convicted of any misdemeanor or felony?*

If yes, please explain:

Current Certifications:*

Languages That I'm Fluent In:*

Position(s) Interested*

Can you work weekdays?*

Can you work weekday evenings?*

Can you work weekends?*

Can you work holidays?*

Month

Day

Year

Describe your experience with emergency medical care (if any).*

Describe your teaching or public speaking background.*

Give an example of when you exhibited leadership skills in an outdoor environment.*

Briefly explain your outdoor/wilderness skills & abilities.*

Do you have any relevant wilderness rescue experience?*

Why do you wish to become a Center for Wilderness Safety staff member?*

List all professional organizations that you are affiliated with.*

Professional Reference (1)*

Professional Reference (2)*

Personal Reference:*

Cover Letter*

Upload Resume*

Upload Your Photo*

Comments or Questions:

Signature