Dear Applicant

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					                               Jefferson County Water Rescue Team
                                   Louisville, Kentucky

Dear Applicant:

Thank you for your interest in becoming a Strike Team member of the Jefferson County Water
Rescue Team (JCWRT). The JCWRT has been deployed in the last few years as an EMAC
resource. The JCWRT Command Staff has decided that operationally in the field and also
having the ability to respond to local responses, that a 24 person team will be the composition
on future team deployments.

Swiftwater / Flood operations involves determining the location of victims trapped in swift /
flood waters, implementing rescue (extrication), and initial medical stabilization. The JCWRT
may be deployed for emergencies or disasters, including hurricanes, storms, floods, and
possibly ice rescues

Members of the JCWRT Selection Committee will review your application and all of the
attached documents. Your application package will be reviewed for training and certification
suitable to your prospective assignment to the Team.

Strike Team members will be organized into a team. In order to be “deployable”, each
member must be fully qualified for their deployment position and have made the team required
training hours for the previous two (2) years. Team members will also be held accountable for
knowing JCWRT’s Policies and Procedures. Team deployments can last up to a period of
fourteen (14) days. Team operating conditions can include a diet of meals ready to eat
(MRE’s) and sleeping on concrete floors with limited housing. Individuals that can not commit
to the deployment time frame and conditions should not apply.

It is preferable that the application be filled out on a computer and then printed for signatures.
If the application is handwritten, it must be printed in ink and be very neat and legible.
The Selection Process will take into consideration the following requirements:
    Applicant submits a completed JCWRT Application Package
    Applicants must have Applicant’s Form signed and attached
    Applicants must have Employer’s Form signed and attached
    Applicant successfully passes the 300 meter SwimTest
    Applicant successfully passes the application review by the Selection Committee
    Letter of Recommendation from Chief
Attach copies or originals of the following, as appropriate: (check as appropriate)
       Valid Kentucky motor vehicle operator license
       EMT or Paramedic license or certificates of training
       Swiftwater Rescue Technician class certificate
       Additional Swiftwater Rescue Training certificates
       NIMS compliance (NIMS 700, 800, 100 and 200)
       Current Fit for Duty

This application packet (with all original signed attachments)
Send to:
Attention: Major Sean Dreisbach
10540 Watterson Trail
Jeffersontown, KY 40299

                                 Applicant Information
Personal Information Please type or print. Use black ink. Answer all questions
Last Name                    First Name         M         Applicant # ( Initials & last
                                                          four Social Security)
Address (street, city or town, state, ZIP code)

Home Telephone                         Business Telephone        FAX Number
    -     -
e-mail:                                      -     -                       -           -
Cellular Telephone                     Pager Number       (check box if alpha-numeric)
     -      -                              -    -
Emergency Contact Name                 Pager Company –

Address (street, city or town, state, ZIP code)

Emergency Contact Home Telephone             Pager/Cell Number         -           -

      -      -                               Work Phone            -           -

Sponsoring Organization/Department/Employer
          Date of Application:


Organization/ Department/Employer Address:              City:                      State:             Zip:

E-mail Address:

                                                                       Current Position Held in
                                                                       Department or Organization:
Business Phone:         -         -

Business Fax #:         -         -
                                                                       How Long in Current Field:
How Long with Current Department or Organization:

                                                                          years      months
From:                       To:

                                      JCWRT Position Interests
                      . See Minimum requirements for each position on page 5
            Please check the position you would prefer to fill:                           The
            JCWRT Command Staff will determine position assignments best suited for the team.

                                           Swiftwater Rescue Squad Officer

                                             assign you
                                              Swiftwater Rescue Specialist

                                             Swiftwater Rescue Technician

                    Special Qualifications
    Medical Qualifications (Paramedic, EMT, etc.) Registration No:

    Special Equipment Licenses (describe- license nos., expiration dates, etc.):

    Other Team Memberships:

    Other Professional Licenses (describe):

          Other Certifications and/or Qualifications (check applicable box)
        Incident Management
               Training                Search & Rescue Operations                               CISD Training

           Rope Rescue                                                                   Speaks         Reads
         (See NFPA 1670)                 Supervisory Experience                      Language other than English
           Ops      Tech
Dear Sponsoring Agency:

An employee or volunteer in your organization has expressed an interest in joining the
deployment team for the Jefferson County Water Rescue Team. As a member of JCWRT, they
will remain employed by their sponsoring jurisdiction, for salary and benefits. It will be the
responsibility of each participating sponsoring agency to clarify with their member how, or if, they
will be compensated for their time, or reimbursed for expenses during deployments. The
sponsoring agency will be required to provide proof of Medical Health insurance coverage and
current Fit for Duty form. In the event of a statewide or national emergency, the applicant may be
activated for a strike team deployment for what could be a period of up to fourteen (14) days.

Print Name of the Strike Team Member/Applicant:_

Name of Applicant (please print)

Name of Sponsoring Agency (please print)

Chief Administrator (please print)

Chief Administrator Signature:_____________________________.

                                                      Date:__ _____        ____________


Full-Time Employer’s Name if different (please print)

 Name of Employer’s Corporate Officer or Owner (please print)

Signature of Corporate Officer or Owner: __________________________.

                                          Date: ___                            __
 These are some of the minimum training levels, based on the component being
 applied for, as specified below.

General Requirements for All Components
    Basic National Interagency Incident Management Systems (NIIMS) incident
     command systems courses (minimum course I -700, I-800, I-100, and I-200)
    Current Fit for Duty
    Met JCWRT training requirements for previous two (2) years
    Successfully passes 300 meter swim
    Hazardous Materials- Awareness
    Certified as a EMT or higher
    Currently certified in CPR
    Maintain current inoculations for tetanus
    These are recommendations, if there are not any contraindications:
     Measles/mumps/rubella (if born after 1957), diphtheria, polio, a current TB test,
     yearly flu, hepatitis A and B vaccines, and smallpox.

Swifwater Rescue Squad Officer
 Comprehensive knowledge of water rescue operations and tactics
 Capable of supervising and directing rescue specialists and technicians in specific
  rescue operations
 Current Emergency Medical Technician – equivalent or higher
 Possess all the certifications and requirements of a Rescue Specialist and Technician
 Swiftwater Rescue Technician Certification

Swifwater Rescue Specialist
 Current Emergency Medical Technician – equivalent or higher
 Swiftwater Rescue Technician
 Have one or more of the following:
                  Rope Rescue Technician
                  Swiftwater Boat Operator

Swiftwater Rescue Technician
 Current Emergency Medical Technician – equivalent or higher
 Swiftwater Rescue Technician
 Two (2) years of swiftwater experience

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