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Disaster Volunteer Registration Form

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Disaster Volunteer Registration Form Powered By Docstoc
					                     Emergency Volunteer Registration Form
PLEASE PRINT CLEARLY

Mr. ___ Mrs. ___ Ms. ___ Name _______________________________________ MI ____ Birth Date _____________

Email address _____________________________________ Cell Phone_____________________ Day Phone ____________________
Home Address_______________________________________________ City__________________________ ST_____ Zip___________
Previous Address: _____________________________________________________________ How long__________
Previous Address: _____________________________________________________________ How long__________
\


    Health limitations, please explain ___________________________________________________________________
VOAD Member? Yes _______ No _______ Occupation____________________________________________________________
Emergency Contact Name ____ _____________________________________ Emergency Phone________________________
SKILLS: Please check all that apply.

    MEDICAL                                SERVICES                              TRANSPORTATION
    ____ Doctor      Specialty:            ____ Food                             ____ Car
             __________________            ____ Elderly/Disabled Assistant       ____ Station Wagon/Mini Van
    ____ Nurse      Specialty:             ____ Childcare                        ____ Maxi-Van, capacity______
             __________________            ____ Spiritual Counseling             ____ ATV
    ____ Emerg. Medical Cert.              ____ Social Work                      ____ Own Off-Road Veh/4wd
    ____ CPR                               ____ Search and Rescue                ____ Own Truck, description:
    ____ Mental Health Counseling          ____ Auto Repair/Towing                    ______________________
    ____ Veterinarian                      ____ Traffic Control                  ____ Own Boat, capacity______
    ____ Veterinary Technician             ____ Crime/Security Watch                  Type:_________________
                                           ____ Animal Rescue                    ____ Commercial Driver License
    COMMUNICATIONS                         ____ Animal Care/Domestic             ____ Camper/RV, capacity
    ____ CB or Ham Operator                ____ Animal Livestock Care                 & type: _________________
    ____ Hotline Operator                  ____ Runner                                ________________________
    ____ Own a Cell Phone                                                        ____ Wheelchair Transport
    ____ Own a Sky Phone #_________        STRUCTURAL
    ____ Public Relations                  ___ Contractor                        LABOR
    ____ Webpage Design                                                          ____ Loading/Shipping
                                           ____ Damage Assessment
    ____ Public Speaker                                                          ____ Sorting/Packing
                                           ____ Metal Construction
    ____ Management                                                              ____ Clean-up/Debris
                                           ____ Wood Construction
    ____ Interviewer                                                             ____ Operate Equipment i.e. Forklift
                                           ____ Block Construction
    ____ Greeter                                                                      Types: ________________
                                           ____ Plumbing
                                                                                      ______________________
                                           ____ Electrical
    OFFICE SUPPORT                                                               ____ Supervising Experience
                                           ____ Roofing
    ____ Clerical - Filing, Copying
    ____ Data Entry -- Software:                                                 EQUIPMENT OFFERED:
                                           SUPPLIES & STORAGE                    ____ Front End Loader
         ________________________          OFFERED:
    ____ Telephone Skills/Receptionist                                           ____ Chainsaw
                                           ____ Please Describe ____________     ____ Generator
                                           _______________________________       ____ Other: _________________
    LANGUAGE/ other than English           _______________________________
    ____ Spanish                                                                      ______________________
                                           _______________________________
    ____ Other: _________________


General availability - days & times:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Additional special skills, vocational training, emergency response training:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Please remember to list all special license numbers on back of form.



                       Wisconsin Emergency Volunteer Management Project, 3.11                                       Page 1
                                         Emergency Volunteer Registration Form (Side two)

                                                 Release of Liability Statement

I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless
the_____________________, ______________ County and local municipality governments, the State of Wisconsin, the
organizers, volunteer team leader, homeowners and fellow volunteers of all emergency preparedness, response and
recovery activities from all liability for any and all risk of damage or bodily injury or death that may occur to me (including
any injury caused by negligence), in connection with any volunteer emergency effort in which I participate. I likewise hold
harmless from liability any person transporting me to or from any emergency response activity. In addition, emergency
response officials have permission to utilize any photographs or videos taken of me for publicity or training purposes. I
will abide by all safety instructions and information provided to me during emergency response efforts.

Further, I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as
permitted by the State of Wisconsin, and that if any portion thereof is held invalid, it is agreed that the balance shall, not
withstanding, continue in full legal force and effect.

I have no known physical or mental condition that would impair my capability to participate fully, as intended or expected
of me.

I have carefully read the foregoing release and indemnification and understand the contents thereof and sign this release
as my own free act.

Signature_____________________________________________________________________                                   Date______________

Guardian, if under 18____________________________________________________________                                Date______________

Volunteer’s credentials were recorded as presented. Verification of credentials is the responsibility of the receiving agency.

Description & License #                                                                      Date issue         Date Expired
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

This volunteer was referred to the following agencies:

Date                   Hours                   Volunteer Assignment                           Agency or Site ________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Notes:
________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Attachments to Application: copy of driver’s license, certifications, backgrounds screening results, referral, additional waivers


    Interview                                       Training                                   Credentials               Verification ID
                                 Basic             Special          Additional

    _________                    _________         _________         ________                   _________                  __________




                      Wisconsin Emergency Volunteer Management Project, 3.11                                                        Page 2

				
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