THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF …



THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.

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| | | |475 Riverside Drive |

| | | |Suite 1929 |

| | | |New York, NY 10115 |

| | | |TEL: (212) 870-2301 |

| | | |FAX: (212) 870-2302 |

| | | |Email: jraneri@ |

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|BOARD OF DIRECTORS | | | |

| | | |REMSCO Critical Incident Response Team |

|Officers: | | |Member Agreement |

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|Walter F. Pizzi, MD, FACS, Chairman | | | |

|Board of Governors | | |I, , apply for membership in the Regional Emergency Medical Services of New York City Critical Incident Response Team. |

|American College of Surgeons | | |I understand that by becoming a member of this team, either as a peer, mental health professional, or clergy, I will be called |

| | | |on periodically to take part in various disaster/crisis management field services. These activities will include but not be |

|Louis Deutsch, Vice Chairman | | |limited to individual contacts, group interventions, and outreach educational programs, as assigned by the Clinical |

|NYS Volunteer Ambulance & | | |Coordinator. |

|Rescue Association | | | |

|District l8 | | |I acknowledge that I will be required to show proof that I have completed the ICISF approved courses of “Basic CISM” and |

| | | |“Individual Crisis and Peer Support”. If I am lacking that training, I agree to take part in the necessary sessions to meet |

|Marvin Raidman, MBA, EMT, Treasurer | | |the training requirements prior to being an active team member. If I am applying to the team as a Mental Health Professional, |

|Major Development, Inc. | | |I will be responsible for obtaining and maintaining professional liability insurance at my own expense. |

| | | | |

|Dorothy Marks, Secretary | | |I agree to take part in any additional trainings that may be required by the team Clinical Coordinator, attend a minimum of |

|Honorary Deputy Commissioner | | |fifty percent of the annual meetings, and commit myself to the program for a period of no less then one year. |

|Fire Department of New York | | | |

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|Members: | | | |

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|Rafael I. Castellanos, Esq. | | |Signature: Date: |

|City & Suburban | | | |

|Real Estate Services, LLC | | | |

| | | | |

|Arthur Cooper, MD, FACS, FAAP, | | | |

|FCCM | | | |

|American College of Surgeons | | | |

|Committee on Trauma | | | |

|Chairperson, Regional EMS | | | |

|Council of NYC | | | |

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|Lorraine M. Giordano, MD, FACEP | | | |

|Director of Medical Oversight and | | | |

|Quality Assurance | | | |

|NYC Health & Hospitals | | | |

|Corporation | | | |

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|Lewis Marshall, MD, JD | | | |

|Chairperson, Regional Emergency | | | |

|Medical Advisory Committee | | | |

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|Donald P. Radenberg, EMT | | | |

|NYS Volunteer Ambulance & | | | |

|Rescue Association | | | |

|District 18 | | | |

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|Steve Zakheim, EMTP | | | |

|Gamzel, LLC | | | |

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|Nancy A. Benedetto, MS, AC | | | |

|Executive Director, Administration | | | |

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|Marie Diglio, EMTP | | | |

|Executive Director, Operations | | | |

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|TAX EXEMPT | | | |

|NOT-FOR-PROFIT CORPORATION | | | |

CIRT Team Applicant Information

*** Please Print all Responses Clearly

Send Application to 475 Riverside Drive, Suite 1929, New York, NY, 10115

Name (Last, First, MI):

Address:

Phone Number: (Home)

(Work)

(Cell/Pager)

E-Mail Address:

← By checking this box, I attest that I am at least 21 years of age.

Credentials/Training

Level of Certification: Please circle one

CFR EMT-B EMT-CC EMT-P

NYS DOH Certification number Expiration Date:

Please check any/all that apply:

Mental Health Professional

Member of the Clergy (denomination)

Fire Fighter/ Hazmat/ Rescue/etc.

Police Officer/ Law Enforcement

Levels (and Dates if known) of ICISF approved classes completed: (Include copies of certificates of completion)

Please list any Degrees, Certifications, or other Relevant Education:

Please outline any significant CISM experiences and/ or activations that you have

participated in:

Do you speak any languages other than English, including Sign Language?

(Please specify)

General availability for Meetings, Educational Presentations, or Activations:

Please list any affiliations to organizations/agencies in the field of Emergency Services, or Mental Health.

Organization Contact number

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