Leading from the front, for a better tomorrow.

The First Response Wellness Foundation believes in providing to communities as much as possible and assisting when we are able to. This form is for Hendricks County, Indiana, Medical Reserves Corp. personnel. This form has been created for Hendricks County to be able to pair trained civilians with mental health professionals if they require assistance following a critical incident they render help with.

While our organization does not provide mental health funding to people who are not law enforcement, dispatchers, firefighters or EMS personnel; we do strongly believe in the mission of the Medical Reserves Corp. and we appreciate Hendricks County taking care of their citizens.

This form is for anyone who is a civilian in Hendricks County that has received training in some form that could provide aide in the event of a crisis within Hendricks County. Your information will be shared with Hendricks County and they will contact you directly.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Are you apart of the medical reserve corps or are you a civilian trained in basic first aid through Hendricks County?

Medical Reserve Corps.

Civilian - Trained by the county.

First Response Wellness Foundation waiver of confidentiality.

I understand that by checking the below box and clicking "SUBMIT", that I am waiving confidentiality of my information and I empower the First Response Wellness Foundation to release all information that was included in this form to outside entities, such as Hendricks County public officials. I also swear and affirm that all information shared on this document are true and accurate as of the time I submitted this form.

I Accept the terms and conditions of the First Response Wellness Foundation.