Volunteer Medical Response Registry- Online Registration

The University of South Carolina must be prepared to respond to campus wide emergencies (i.e. pandemic flu outbreak, large natural disaster, etc.). In the unlikely event of a campus emergency, it would be necessary to identify useful medical personnel and utilize their training. In a joint effort, Student Health Services and Student Government are creating a registry of current students who possess medical training and certifications so that an emergency contact and call-up list can be available in the event of such an emergency.

If you are a student that possesses a current health professional certification, please take a moment to complete the information below to be added to the volunteer medical response registry.

First Name:     MI:     Last Name:

Local Address:
City: State:   ZIP:

Local Phone:     Cell:     Pager/Other:     Email:

Gender: Male Female     Age:     Valid Driver's License? Yes No    
From What State/Province?

Expected Graduation Date: May August December 2006 2007 2008 2009 2010 2011 2012

Type or Level of Health Professional Certification: First Responder EMT-Basic EMT-Intermediate EMT-Paramedic Certified Nursing Asst. (CNA) Licensed Practical Nurse (LPN) Registered Nurse (RN) Nurse Practioner (NP) Physician's Assistant (PA) Pharmancy Tech Other (describe)
If other,

State Level Certification, License, or Registration:

Agency:

Type:    

Number: Expires:

National Level Certification, License, or Registration:

Agency:

Type:    

Number: Expires:

I certify that the above information has been provided voluntarily and I understand I am under no obligation to participate in any volunteer medical response situation if I choose not to. I understand that if called up, I may be asked to provide proof of the above certifications.

I understand that the above information will only be used by Student Health Services and Student Government in regards to the volunteer medical response system and will be kept confidential. The only contact I will receive is in the event of a campus emergency or to periodically update the database.

I certify that, to the best of my knowledge, the above information is correct and true.

Signature: (Type Full Name)    
Date:

If you have any questions regarding this form, registration process, or the volunteer medical response system, please contact:

Christopher Gainey, Secretary of Health Services

Office of Student Government, Russell House 227    Phone: (803) 777-2654    Email: cgainey@sc.edu