Candidate Information
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First Name
Last Name
*
Email Address
Social Media Name
*
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Phone Number
Committee Interests?
Please indicate what area you would like to contribute.
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Country that you reside
Town/Providence/Parish
*
Department Name
Years in the profession?
*
Commanding Officer /Supervisor
Contact Phone Number
Background
Member of a Task Force Team?
*
No
Yes
N/A
If Yes, Task Force Name and Country?
Member Affiliation
*
Please Select
Caribbean Association of Firefighters
Caribbean Association of Fire Chiefs
Caribbean Fire/EMS Agency
Caribbean Emergency Disaster Management Agency
Chief Medical Officer (Caribbean)
Caribbean Hospital-Based EMS
Caribbean EMS Contractor
Caribbean Military
Level of Education
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High School
Secondary School
Associate Degree
Bachelor's Degree
Master's Degree
Post Graduate Degree (PhD, EDD, etc.)
Doctor of Medicine
Agency Type
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Fire Department
Rescue Squad
Community Emergency Response Team
Dispatch Center
Law Enforcement
Ambulance Company
Military
Volunteer Department
Other
Current Function/Position
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Please Select
Firefighter
Chief Fire Officer
Driver Operator
Corporal
Sub Officer
Rescue Specialist
HazMat Specialist
Aircraft Rescue Firefighter
Station Officer
EMS Supervisor
EMS Provider
Lead Firefighter
Medical Doctor
Nurse
Area of Responsibility
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Please Select
Administration Field Operations (Fire)
Command Staff
Communications
Community Emergency Responder
Educational Institute/College
Field Operations (EMS)
Field Operations (Rescue)
Fire, EMS, RescueTraining Division
Hospital
None of the above
Level of Certification Requested?
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Please Select
Certified Fire Officer
Certified EMS Officer
CERT Trained
Dispatcher/Communications Specialist
Doctor
EMR/First Responder
EMT Basic
EMT Intermediate
EMT-Paramedic
Firefighter
Junior Fire Officer
Rescue Technician
Station Officer
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Certificate/Training
Name of training facility?
Card/Certificate #
Credentialed by?
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National Registry
Canadian Registry
United Kingdom
University of the West Indies
Local Training Center
NCTVET
Other
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Career Status?
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Volunteer
Temporary
Permanent
Other (seasonal from overseas)
Non applicable
Senior Officer Leadership Academy (SOLA)?
*
Please Select
Yes
No
Junior Officer Leadership Academy (JOLA)?
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Please Select
Yes
No
No, but interested
If yes, date attended JOLA?
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Month
-
Day
Year
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Proof of JOLA Training
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Int'l Trauma Life Support Training?
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Yes
No
No, but interested
Trauma Life Support Date of Completion
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Month
-
Day
Year
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Proof of ITLS/PHTLS/TECC Training
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EMS Credential Expiration?
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Month
-
Day
Year
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EMS Date of Completion
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Month
-
Day
Year
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EMS Training/Certificate
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Current CPR Card (required)
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Other Credential To Support Request
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Other Credentials
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Other Information
CAFC Conference Training Interest?
Please Select
Airway Management
Advanced Cardiac Life Support
Advanced Medical Life Support
Active Shooter Training
Basic Life Support
EKG Recognition
Firefighter Skills
Forcible Entry Training
Incident Command System
Leadership Development Training
Live Fire Training
Mass Casualty Training
Pediatric Advanced Life Support
Testing for Credentials
Trauma Management Training
Vehicle Extrication Training/Competition
None/Conference Only
Interested in EMS Competition?
*
Please Select
Yes
No
Interested in Firefighter Competition?
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Yes
No
Interested in Extrication Competition?
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Yes
No
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