Rail Safety for Emergency Responder Instructor Application

Criteria and Minimum Standards for Instructors

Unless otherwise noted, all fields are required
First Name    MI (opt):
Last Name   
Title   Organization 
Work Address   
Work City / State / Zip   
Work Phone /Fax Ph:  Fax:
Home Address   
Home City /State / Zip   
Home Phone /Cell Ph:  Cell (opt):
Email   
Please read and respond to the following statements:
1. I have carefully read, fully understand, and agree to abide by the RSER Instructor Criteria and Minimum Standards YesNo 

2. I  have carefully read, fully understand, and agree to
the RSER Instructor Information		 YesNo

3. Have you ever been convicted of a Felony? If yes, a representative from Operation Lifesaver will contact you.		 YesNo
Public Speaking
Part A: How many years of experience do you have in public speaking? Preferred minimum of one year of experience.
 
Part B: Please describe relevant experience, formal education or training in public speaking 
 
Part C: Provide a brief summary of your last two public speaking events to include: dates, locations, type of audience, number in attendance and topic.
 

Training

Please note, Operation Lifesaver Presenters are not instructors, but do support public speaking involvement. Operation Lifesaver Trainers do qualify as instructor credentials.
Part A: List instructor training, certificates, college or formal education instructor courses, assistant instructor involvement, teaching degree or any other information that supports an instructor's background.  
 
Part B: Provide a brief summary of your last two training sessions to include: dates, locations, type of audience, number in attendance and topic.
 

Background and Knowledge
Part A: Please describe your background and knowledge in any of the following categories: basic railroad, fire fighter, law enforcement, emergency management, military or equivalent demonstrated knowledge. (If you have background/knowledge in an equivalent area, please provide a detailed description.)
 
Part B: Describe your job experience, formal education, training, certificates and commissions issued in the above fields.
 

Skills and Abilities
Part A: List any special skills and abilities pertinent to railroad equipment, operations and technology; eg. Certified Engineer, Hazmat Specialist, Federal Railroad or State Railroad Inspector, etc.
 
Part B: List any other special skills and abilities that may be pertinent to this application for the RSER Instructor
 

 

References
Please list 3 supporting references. Include names, addresses and phone numbers
1.  
2.  
3.  

 

Other
How did you hear about this opportunity?
 

Optional: Submit your resume (txt, doc or PDF format please)
 
Signature of Agreement. Please Read Carefully
I declare to the best of my knowledge that the information provided by me on this application is true, correct and complete. I understand and hereby authorize OLI to conduct a background check regarding information provided on this application and my background in general, including but not limited to any charges and/or convictions I may have had for violation of municipal, county, state or federal laws since reaching the age of majority (legal age). This information may be gathered from any source, including any law enforcement agency of this state or federal government, or from third-party providers of information originally obtained from law enforcement or court records. I also understand that any falsification or omission will be grounds for immediate removal from this program.
YesNo 
Your information will be sent to the GCCI Application Review Committee. If you have questions about your application, or if you encounter a problem while trying to submit your application, please contact Ken Gilsdorf at kgilsdorf@woh.rr.com.