Indiana Crisis Assistance Response Team (I-CART)

TEAM APPLICATION


I. Title: ___ First Name:____________ MI:_____ Last Name:_____________________

HOME INFORMATION
Address: _______________________________________________________

_______________________________________________________

Phone: ________________________ Cell Phone: ______________________

E-Mail: _________________________________________

WORK INFORMATION

Agency/Position:_________________________________________________

Address: _______________________________________________________

________________________________________________________

Phone: ________________________ Cell Phone: ______________________

Email:____________________________________________

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, Signed Memorandum of Understanding, Signed Code of Ethics, 2 References and copies of Training Certificates, along with a $10 application fee (to help cover the cost of a background check), to:   

I-CART 

Attn: Membership Files                
P.O. Box 44168
Indianapolis, IN 46244-0168

Questions can be directed to I-CART at (317) 596-2202.