Alamo Medical Response Group

TEXAS STATE GUARD MEDICAL BRIDADE

DEPLOYMENT INFORMATION

DEPLOYABLE ____                   NON-DEPLOYABLE ____

Page 1 & 2 and Required Copies will be given at Point of Check-In.  Complete Packet will remain with soldier.

RANK: _________                             MOS: ____________________________________

NAME: Last: ___________________ First: ________________________ MI: _______

ADDRESS: ______________________________ CITY: _________________ ZIP: _________

CELL PH: ___________________ HOME PH: ________________ BUSINESS: __________

EMAIL: ____________________________

SS #: _________________________________ DL # _______________________ ST: ____

BILINGUAL: Y ___ N ___ LANGUAGE(s): ________________________________________

(If in POV):

AUTO LP#:_______________ ST: ___        VEHICLE TYPE: _______________________

MODEL: _____________________ COLOR: _____________________

AMATEUR RADIO LICENSE: ____________ CLASSIFICATION: ___________________

CONCEALED HANDGUN PERMIT #: __________________ EXP. DATE: _____ ST: ___

RELIGIOUS PREFERENCE: _____________________________

MARRIED ___ DIVORCED ___ SINGLE ___ WIDOWED ___ DUAL SERVICE PARENT___ SEPERATED ___ FIANCEE’___

IN CASE OF AN EMERGENCY, CONTACT:

NAME: ________________________________________ RELATIONSHIP: _______________

ADDRESS: _____________________________________________________________

CITY: ______________________________ STATE: ____ ZIP: ___________________

IMMUNIZATIONS: TETANUS _____ DATE: ________   HEP B: ______DATE: ________

OTHER IMMUNIZATIONS AND DATES: ________________________________________

______________________________________________________________________________

PHYSICAL DISABILITIES: ____________________________________________________

ALLERGIES: _________________________________________________________________

PERSONAL EQUIPMENT NEEDED: ____________________________________________

SPECIAL SKILLS: ____________________________________________________________

2 COPIES:

__ TX Drivers license

__ Social Security Card

__ Concealed Handgun Permit

__ Amateur Radio License

__ TXSG ID Card

__ BLS Card

__ ACLS Card

__ TX Professional License (MD, DDS, DO, DVM, RN, PA, LVN, EMT, etc.)

__ DEA Permit (for providers permitted to prescribe controlled substances)

__ DPS Permit (for providers permitted to prescribe controlled substances)

__ OTHER CERTIFICATIONS __________________________________________________

     ____________________________________________________________________________

NOTE:

PAGE 1 & 2 AND COPIES ARE REQUIRED AT CHECK-IN

PAGES 1-5 AND COPIES WILL ALSO REMAIN IN SOLDIER’S POSSESSION DURING DEPLOYMENT.

DUTY LOCATION ASSIGNED: ________________________________

BILLETING LOCATION: _____________________________________

DATE PROCESSED:  IN ______________ OUT: ______________

SIGNATURE OF RECEIVING OFFICER: _________________________________________________

RANK: ____________________ DATE: _______________________ CHECK-IN LOCATION: ____________________________________

TEXAS STATE GUARD DEPLOYMENT INFORMATION

RANK: ________       UNIT: _________________  MOS: ___________________________

LAST NAME: _______________________ FIRST NAME: _____________________ MI: ___

SSN: ____________________ DL: ________________________ ST: ___ DOB: ____________

HOME ADDRESS: __________________________________ EMAIL: __________________

CITY: ___________________________ ST: _____ ZIP: ______________

HOME PH: _____________________________ CELL PH: ________________________

OFFICE PH: ____________________________ PAGER: __________________________

AMATEUR RADIO LICENSE: __________ CLASSIFICATION: _____________________

MEMS: (circle one) BASIC        ADVANCED               MASTER

REQUIRED INDIVIDUAL MEMS COURSES: (if basic is not complete. circle) 100 200 700 800

OTHER MEMS COURSES COMPLETED: ________________________________________

OTHER COURSES COMPLETED: (ex: Haz-Mat, WMD, Fire Suppression, etc.)

______________________________________________________________________________

GUN CONCEALMENT LICENSE: Y___ N___ License #: ______________ Exp. Date: ____

PROFESSIONAL LICENSE(S) # & EXP. DATE(S) (Including Dr., Rn, PA, EMT, etc.): ______________________________________________________________________________

CPR/BASIC FIRST AID: Y ___ N ___         BLS: Y___ N ___       ACLS: Y ___ N___

ATLS: Y ___ N ___    BDLS: Y ___ N ___    CLS (Combat Life Saver) Y ___ N ___

SPECIAL SKILLS: ____________________________________________________________

 ______________________________________________________________________________

IMMUNIZATIONS:  TETANUS ___ DATE ________        HEP B ___ DATE __________

OTHER IMMUNIZATIONS & DATES: ___________________________________________

PERSONAL PHYSICIAN: ________________________________ PH: __________________

ALLERGIES: _________________________________________________________________

EMPLOYMENT

Soldiers Work Status:  Fulltime ___ Part-time ___ Self-Employed ___ Unemployed ___

Employer’s Name:  _________________________________________ PH: ________________

MARITAL STATUS

Married __ Single __ Divorced __ Widowed __ Dual Service Parent __ Separated __ Fiancee’__

SPOUSE NAME: ___________________________________  Relationship: _____________ 

Primary Language: ________________ EMAIL: ____________________________________

HOME ADDRESS: ____________________________ HOME PH: _____________________

CITY: ________________ ST: __ ZIP: ____________ CELL PH: ______________________

WORK STATUS: Fulltime __ Part-Time __ Self-Employed __ Unemployed __ Student __

SPOUSE EMPLOYER’S NAME: ________________________________________________

EMPLOYER’S ADDRESS: _____________________________________________________

In case of an EMERGENCY, is your spouse the primary point of contact? YES __ NO __

IF NO, PRIMARY POINT OF CONTACT: ________________________________________

Relationship: ______________________ HOME PH: ____________________

CELL PH: ______________ WORK PH: ______________ EMAIL: ____________________

HOME ADDRESS: _____________________________________________________________

Is spouse expecting a child: YES __ NO __ Due Date if Applicable: ______________________

RANK & NAME: ________________________________________________________

DATE: ___________________________________

“GO BAG CHECKLIST”

ALWAYS BE PREPARED!

BE SELF CONTAINED FOR AT LEAST 72 HOURS!

1. ___ PERSONAL INFORMATION PACKET Including IDENTIFICATION (including immunization updates, Emergency Telephone Numbers, etc.)
2. ___ PERSONAL MEDICATIONS
3. ___ * Radio/Communications, Headphones  (Extra Radios, Antennas, Coax, Connectors, Batteries and/or Recharging Capabilities) (For Soldiers With Commo Gear/Duty) *
4. ___ * Cell Phone and Extra Battery or Recharging capabilities (if able to use in an emergency) *
5. ___ Full tank of gas in Vehicle (This should be done at the closest fuel stop to the disaster)
6. ___ Cash for Personal Needed Items (REMEMBER:  In most disasters, catastrophic events, etc., credit cards, checks, etc., MAY NOT be of use due to electrical outages or other unknown events.  ALWAYS plan on cash as the main monetary source!  Carry cash denominations of less than $50.00 bills.)
7. ___ Weather Radio and “Good Time Radio” for News Alerts
8. ___  ACU/BDU’s (Including Boots, Cap/Cover, and Boonie/Jungle Hat) and off duty clothing
9. ___ Extra Footwear and Socks for Environment and Work Gloves
10. ___ All Weather Gear
11. ___ Towel & Wash Cloth
12. ___ Personal Items & Toiletries including toilet paper (For WOMEN, personal feminine products)
13. ___ Canteen(s), Camel Back, or Way of Transporting Water
14. ___ Web Belt and/or M.O.L.L.E. lbe vest
15. ___ Mess Kit and Eating Utensils
16. ___ Sleeping Cot, Sleeping Bag/Bed Roll, and Pillow
17. ___ Insect Repellant
18. ___ Sun Block or Suntan Lotion
19. ___ Food (Vienna Sausage, Spam, Tuna Fish, Canned Chicken, MRE’s, etc.)
20. ___ Water, Gatorade, etc. (refrain from carbonated drinks)
21. ___ Snacks (High Energy Snacks such as Chocolate bars, granola bars, peanut butter, etc.)
22. ___ First Aid Kit (Small One for individual use and Large for Multi-Use)
23. ___ GPS Unit and/or Compass (if you have one)
24. ___ Maps for the area (if available)
25. ___ Flashlight and extra batteries
26. ___ Knife and/or Machete
27. ___ Matches (waterproof preferred) or cigarette lighter
28. ___ Clipboard, Paper, Ink Pen (At least one of each item)
29. ___ Small Portable Table and Chairs or Stools
30. ___ Small Shovel
31. ___ Aerial Flares, Reflective Mirrors, Smoke “bombs”, Non-Flammable Flares
32. ___ Ice Chest(s)
33. ___ Paper Towels

Other Items To Be Considered To Have “Ready To Go” If Needed:

Tent, Campstove and Fuel, ATV, RV, Marking Ribbon or Flagging, Small hand tools, Generators and Extra Fuel, etc.

*REMEMBER:  In the first hours, possibly days, of a disaster, accessory battery charging capabilities may ONLY be accomplished by automobile.  Make sure you pack your auto chargers.

VERIFIED BY:  Name & Rank ______________________________ DATE_______________

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