Get Worker Registration Form

I. Member Organization CRESA EOC Telephone Home Mobile Work E-mail s Amateur Radio Call Sign if licensed Physical/Home Address Street City State Zip Code Mailing Address if different Street Date of Birth // Blood Type Select One Male Female Color Hair Driver s License Height feet inches Weight Color Eyes Physical disabilities if any restrictions In case of emergency please notify Name Relationship Phone For emergency worker print sign and deliver to your Training Coordinator I certify that the information on this card is correct to my best knowledge and belief. Emergency Worker Signature Date FOR TRAINING COORDINATOR ONLY In what field is this emergency worker qualified to operate General organization and that the worker complies with all the training standards and requirements of this organization. this class of worker as stated in WAC 118-04-100 and all other requirements of Clark Regional Services Agency and law enforcement agencies within Training Coordinator Name Signature or send by email Forward completed form to CRESA. Emergency. Management clark. wa.gov or CRESA Attn EM Worker Registration 710 W. 13th St. Vancouver WA 98660 Authorized Official - FOR CRESA ONLY What is the class of this emergency worker as defined in 118. 04. 100 Administration Aviation Communications Engineering Fire Service 6. General 7. Hazardous Materials 8. Volunteer Emergency Worker Registration Clark County Washington Pick One New Registration Renewal Change of Information Replacement Card Card Leave blank for new registrations Last Name First Name M. I. Member Organization CRESA EOC Telephone Home Mobile Work E-mail s Amateur Radio Call Sign if licensed Physical/Home Address Street City State Zip Code Mailing Address if different Street Date of Birth // Blood Type Select One Male Female Color Hair Driver s License Height feet inches Weight Color Eyes Physical disabilities if any restrictions In case of emergency please notify Name Relationship Phone For emergency worker print sign and deliver to your Training Coordinator I certify that the information on this card is correct to my best knowledge and belief. Emergency Worker Signature Date FOR TRAINING COORDINATOR ONLY In what field is this emergency worker qualified to operate General organization and that the worker complies with all the training standards and requirements of this organization. this class of worker as stated in WAC 118-04-100 and all other requirements of Clark Regional Services Agency and law enforcement agencies within Training Coordinator Name Signature or send by email Forward completed form to CRESA. Volunteer Emergency Worker Registration Clark County Washington Pick One New Registration Renewal Change of Information Replacement Card Card Leave blank for new registrations Last Name First Name M. I. Member Organization CRESA EOC Telephone Home Mobile Work E-mail s Amateur Radio Call Sign if licensed Physical/Home Address Street City State Zip Code Mailing Address if different Street Date of Birth // Blood Type Select One Male Female Color Hair Driver s License Height feet inches Weight Color Eyes Physical disabilities if any restrictions In case of emergency please notify Name Relationship Phone For emergency worker print sign and deliver to your Training Coordinator I certify that the information on this card is correct to my best knowledge and belief* Emergency Worker Signature Date FOR TRAINING COORDINATOR ONLY In what field is this emergency worker qualified to operate General organization and that the worker complies with all the training standards and requirements of this organization* this class of worker as stated in WAC 118-04-100 and all other requirements of Clark Regional Services Agency and law enforcement agencies within Training Coordinator Name Signature or send by email Forward completed form to CRESA.