Special Forms Application

Lincoln County

Special Teams Request Form
Office of Emergency Management Office of Emergency Management

34 Bath Road, P.O. Box 249 Wiscasset, Maine 04578 Phone: (207) 882-7559 Fax: (207) 882-7550
Special Teams Request Form
Name*
Phone Number*
Please enter a valid phone number.
Special Team Request*
Date of Birth*

MonthDayYear
Date
Height*
Weight*
Eye Color*
Hair Color*
Date of issue*

MonthDayYear
Date
Medical Information
Allergies
Medical History (If wanting to include anything)
Emergency Contact Information
Name Of Emergency Contact *
Phone Number of Emergency Contact *
Any Additional Specialties?
ICS (Incident Command System

Basic (ICS 100, 700, 800)Intermediate (ICS 100,200,700,800)Advanced (Intermediate Courses and ICS 300 and 400)None
Additional Options

Fire FighterEMTFirst Aid/CPROther
Please Specify On Additional Options If Any Chosen
Can include Fire Fighter Level, EMT License Number, ECT.
Please Upload a Photo of Yourself

Please make sure all photos are clear and in a well lit space. We need to be able to see your face clearly along with hair color! You can either upload a file you have already or take a photo using the take photo button below.
File Upload*

Cancelof
Take Photo
E-Signature
I attest to the accuracy and integrity of this document and all information to be true and not intentional or knowing falsification. A person who intentionally or knowingly falsifies, Provides false information, makes or alters any certificate or certified copy knowingly commits a crime and can be prosecuted under Maine State Law. Entering my name in the box below is a representation of my signature for this document - just the same as pen and paper signature.
Name

First NameLast Name
Please contact Lincoln County EMA @ 882-7559 with any questions
Should be Empty:

Lincoln County

Special Teams Request Form

Medical Information

Emergency Contact Information

Any Additional Specialties?

Please Upload a Photo of Yourself

E-Signature