Indiana Crisis Assistance Response Team (I-CART)
TEAM APPLICATION
I. Name/Title: ___________________________________________
HOME INFORMATION
Address: _______________________________________________________
_______________________________________________________
Phone: ________________________ Cell Phone: ______________________
E-Mail: _________________________________________
WORK INFORMATION
Agency/Position:_________________________________________________
Address: _______________________________________________________
________________________________________________________
Phone: ________________________ Cell Phone: ______________________
Preferred Place of Contact: Home Work
List any medical conditions that others should be aware of:_______________________________
_________________________________________________________________________________
In case of emergency, contact: Name:_________________________________________________
Phone:__________________ Relationship: __________________
II. COLLEGE / OTHER CERTIFICATION:
Institution Degree Major
___________________________________ _________________ _________________________
___________________________________ _________________ _________________________
___________________________________ _________________ _________________________
List any current license(s) or certification, including licensure numbers/dates:
Type Agency State
___________________________________ __________________ ________________________
___________________________________ __________________ ________________________
III. Training/Expertise:
NOVA CISM Red Cross School Crisis Team
Other: (list and describe)
_____________________________________________________________________________
_____________________________________________________________________________
IV. AREAS OF EXPERTISE
A. Languages other than English in which you are fluent, including signing:
_____________________________________________________________________________
_____________________________________________________________________________
B. List any special populations with which you have experience:
____________________________________________________________________________
____________________________________________________________________________
V. AVAILABILITY
A. Is your employer willing to release you from work to be part of a trauma response team?
YES NO Depends of Circumstances __________________________________
B. Generally speaking, when would you be available?
During Day During Evening Early Morning Weekends
Are there holidays during which you are usually in town and could be available?
____________________________________________________________________________
____________________________________________________________________________
Other information about your availability: _______________________________________
____________________________________________________________________________
____________________________________________________________________________
VI. Please provide any other information you believe pertinent to your application, or attach a separate letter. __________________________________________________________________
________________________________________________________________________________
I acknowledge all of the enclosed information is true. I hereby authorize persons on behalf of the Indiana Crisis Assistance Response Team to search files and records of the justice system for any criminal history information. I understand the results of a search, and material contained in this application, shall remain confidential, and shall be reviewed to determine my suitability for inclusion in any I-CART response team deployment. There may be situations that information received could result in someone being found to not be an appropriate member for I-CART responses or purposes.
Applicant’s Signature _____________________________
Applicant’s Printed Name ______________________________
Date of Application ____________________
Date of Birth ______________
Social Security Number _______________________
Return Completed Application, Memorandum of Understanding, Code of Ethics, 2 References and copies of Training Certificates to: I-CART
8605 Allisonville Road
Indianapolis, IN 46250-1552
Questions can be directed to I-CART at (317) 596-2202.