1. Registration Form

Thank you for your willingness to serve as a volunteer for the Kidney Community Emergency Response Coalition. This list will serve as a means to quickly identify volunteers. Please complete the following information as the first step to be a volunteer of this emergency preparedness network.

Registering as a volunteer does not necessarily mean you will be called for every disaster that occurs. People will be called as needed.

Please note that volunteers will be responsible for their own transportation to the disaster area.

* 1. Contact Information

* 2. What is your renal nutrition specialty? (Please check all that apply.)

* 3. Experience

* 4. Experience - Please summarize your experience in renal nutrition.

* 5. Are you currently certified in the following:

  Yes No
BLS (Basic Life Support)
ACLS (Advanced Cardiac Life Support)

* 6. What type of job or task are you willing to perform?

* 7. Are your vaccinations current for the following?

  Yes No
Tetanus & Diphtheria (TD)
Hepatitis B
Annual TB Check

* 8. Please indicate below that you:

* 9. Other Comments

* 10. The National Disaster Medical System (NDMS) oversees Disaster Medical Assistance Teams (DMAT) that deploy in times of emergency. There is a proposal before the NDMS to have a kidney provider staff who can be federalized and deployed in case of a disaster. If this happens, this information may be forwarded to NDMS. Can we forward your information to NDMS at that time?

* 11. For Council on Renal Nutrition Use Only

* 12. The information provided above is true and correct to the best of my knowledge.

Please click "Next >>" once you have completed the above information.