Volunteer Application

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					                                    HUNT COUNTY, TEXAS
                           COMMUNITY EMERGENCY MEDICATION CLINIC
                               STRATEGIC NATIONAL STOCKPILE

                                               VOLUNTEER APPLICATION
Please PRINT LEGIBLY and complete ALL information requested
      Non-Medical duties
      Medical related duties (below specify the type of license/certification you hold


Name ___________________________________________________gender: male                                                     female
              Last                             first                          middle

Address (full rural “911” if applicable) ________________________________________________________________
                                                                           Address                                      apartment

               City/town                                           state                            zip code

_____________________________ __________________________________ __________________________ ________________________________________
     home phone                          work phone                        cell phone                      pager/other

__________________________________________     ________________________________________________ _____________________________________
         email-home                                             email-work                            email-other

Occupation_______________________________Employer______________________________________

Drivers License Number_________________________________State_____ Expiration date__________
Emergency Notification ______________________________________________________________________
                                             Name                      relationship             contact phone numbers

Volunteer Requirements:
        1. Submit complete application form
        2. Be at least 18 years of age
        3. Hold a valid and current Texas drivers license
        4. Have no felony convictions for DWI, Drug offenses, Sexual, Family violence
        5. Participate in training sessions
        6. Comply with worker/volunteer standards established by this jurisdiction
        7. Notify the jurisdiction when terminating volunteer status, or when personal or contact
            information changes
        8. Be available on short term notice to assist

See the reverse, or attached sheet, for more needed information
I have read and understand the above listed requirements. I attest to the accuracy of the information I have
provided on this application.

Signature_______________________________date_________________received by___

Return to: Hunt County BT Response Planning Coordinator P.O. Box 1097 Greenville, Texas
75403

For information : 903-408-4188 rwood@huntcounty.net                                      www.huntcounty.net




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                             HUNT COUNTY, TEXAS
                    COMMUNITY EMERGENCY MEDICATION CLINIC
                        STRATEGIC NATIONAL STOCKPILE

                                   VOLUNTEER APPLICATION INFORMATION

The purpose of this information is to identify the volunteer duties that would utilize your skills to the
best benefit of the medication clinic services. This does not constitute or commit the volunteer or the
medication clinic managers to a definite assignment.

Please check the boxes which best describe your skills and capabilities.

NON MEDICAL                                                                 MEDICAL

____patient registration                                                ____medical triage

____patient orientation                                                 ____medical screening

____administrative                                                       ____medicine dispensing

____clerical                                                             ____medicine inventory

____food service                                                         ____medical evaluations

____crowd control                                                        ____Physician

____security                                                             ____PA

____housekeeping/custodial                                               ____nurse

____translator                                                           ____Pharmicist

____computer technician                                                  ____Dentist

____transportation                                                       ____Veterinarian

____runner                                                               ____EMT/Paramedic

____other                                                                ____other

explain special training and skills you have which would be helpful in providing the services at a
Dispensing Clinic in a biological crisis, or skills you would offer in developing this plan prior to an
event.




___________________________________________________________________________________________________________________________




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