BCVFD Medical Training Patient Survey

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Please fill out this form so we can choose the best scenario for you

Name *

Phone Number *

Birth Date *

YYYY

Are you 18 years or older? *

Yes

Sex *

Female

Male

Prefer not to say

Actual Medical Conditions

Area of Interest *

Any

Trauma

Psychological

Medical

Required

Willing to have clothing removed? *

A layer of clothing under the layer that will be removed is recommended. The under-layer may be as conservative as you like. It is up to you to decide what is removed and what must stay. Any participant under the age of 18 must be fully clothed at all times with no excessively revealing clothing.

Yes

Previous Acting Experience?

Yes

Clear selection

Do you have any medical training?

EMR

EMT-B

EMT-A

Paramedic

Military Medic

Nurse

Doctor

Other:

Clear selection

Any information you would like us to know?

By typing my name below, I certify that I am the participant listed on this form, and I understand that this may include depictions of actual illnesses or traumatic injuries. The scenarios are designed to be as lifelike as possible and will include real and/or simulated assessment and treatment. *

Please type your full name as it appears on your driver's license or state issued ID card.

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