VOLUNTEER APPLICATION OIL SPILL RESPONSE Louisiana State Animal Response Team

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17 Οκτ 2013 (πριν από 3 χρόνια και 10 μήνες)

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VOLUNTEER APPLICATION



OIL SPILL RESPONSE

Louisiana State Animal Response Team

LVMA
-
L
SART, 8550 United Plaza Blvd.,
Suite 1001,
Baton Rouge, La. 70809

(800)

524
-
2996; (225)

928
-
5862 fax: (225)

408
-
4422

website:
www.lsart.org




Last Name:






First Name:






Middle Initial:








Phone Numbers (home):





(cell):





(work):







Address:







City:






State:






ZIP:







Email Address:







LA Resident:
Yes
No Home Parish:









RESPONDER CATEGORY

(check any that apply)
:


LSART

Member


LACA Member



LVMA

Member



L
A
WRA Member


LSU SVM Student
-

Grad
Year









LSU SVM Faculty/Staff


DOCUMENTATION REQUIRED:

(return with this volunteer information form
-

electronic copies okay
)

1.


Passport type

color
photo
(mandatory
-
for LSART ID card)

2.


Copy of Driver’s License, front and back

(mandatory)

3.


Copy of each Cert
ificate of Achievement for FEMA ICS
&

NIMS

Training/ HazMat Training

4.


Copy of BP OIL Spill form HSEREH003

(mandatory)


ANIMAL HANDLING:


(
check all that apply)

Rate Experience with Animals
:*






Minimal


Moderate


High






Cats
/Dogs











Horses












Cattle/Livestock










Exotics
/Wildlife









What

Species
?










MEDICAL TRAINING:

Physician


Nurse

EMT/Paramedic


Red Cross (Type





)

Veterinarian


Vet Tech

Vet Assistant


Permitted

Rehab (Type






)



OIL SPILL RESPONSE TRAINING:



HazCom

Training



Haz
WOPR Training



BP HazMat Orientation


RESPONSE CATEGORY:



Decontamination



Rehabilitation


Where needed


AVAILABILITY
,
SUMMER
:




Any date


Weekends only

(Sat
-
Sun)


Weekdays only

(M
-
F)



I am availab
le on these specific dates:








I am unavailable on these specific dates:






*Examples of animal handling experience: Minimal Experience

“I have a pet
.
” Moderate Expe
r
ience “I volunteer at a shelter.”



High Experience “
I am an
Animal Control Officer, Certified Animal Rescuer,
Veterinarian, Registered Veterinary Technician.”