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. |
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|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 | | | |
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|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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