BCEMS Survey

Survey Questions

Participant First Name? *

Participant Last Name? *

Participant Phone Number? *

Particiant Email? *

Participant Date of Birth *

Emergency Contact Name *

Emergency Contact Phone *

VOLUNTEER PARTICIPATION WAIVER AND RELEASE OF LIABILITY Event: Mass Casualty Incident (MCI) Training Exercise Host Organizations: Bryan County EMS & Heartland Medical Direction Description of Activity & Initial Acknowledgment I understand that I am voluntarily participating (or permitting my minor child to participate) as a simulated patient or victim actor in a mass casualty training exercise. *

I Do Not Agree I Agree

I specifically acknowledge and agree that participation may involve: Moulage & Fake Blood: Application of makeup, latex, theatrical prosthetics, and simulated blood products to skin and clothing. (Note: Simulated blood and makeup may stain clothing or personal belongings). Patient Handling: Being moved, carried, placed on stretchers, or positioned by emergency medical personnel. Simulated Treatments: Application of non-invasive medical equipment, including splints, bandages, cervical collars, and monitoring devices. *

I Do Not Agree I Agree

Please list any known allergies (especially latex, adhesive, topical cosmetics, or blood substitutes) or physical limitations that organizers should be aware of: *

Assumption of Risk & Release of Liability I understand that while safety protocols are strictly enforced, active training environments carry inherent minor risks of physical exertion, accidental trips, slip hazards, or mild skin irritation from cosmetics. In consideration for being allowed to participate, I, for myself (and on behalf of my minor child/ward), hereby release, waive, and hold harmless Bryan County EMS, Heartland Medical Direction, their officers, employees, agents, and instructors from any and all liability, claims, or demands arising out of participation in this exercise. *

I Do Not Agree I Agree

Photo & Media Release (Optional) I grant Bryan County EMS and Heartland Medical Direction permission to use photos or video recordings taken during the exercise for internal training, public relations, or promotional purposes. *

Agree to Media Release Decline Media Release

Signature: By executing this form electronically, you certify that the information provided is accurate and complete, and you acknowledge that you have read, understood, and agreed to the terms of this waiver. *

Parent / Legal Guardian Consent (Required if Participant is under 18): I affirm that I am the parent or legal guardian of the minor listed above. I have read and understand the terms of this waiver, confirm that all information provided is accurate and complete, and grant permission for my child to participate under these conditions. By signing below, I agree that my signature constitutes an electronic signature with the same legal effect as a handwritten signature.

Training Participant Wiaver