Disaster Volunteer Registration Form

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Disaster Volunteer Registration Form Powered By Docstoc
					                           Emergent Volunteer Registration                                                   Form 105
                                    Please Print Clearly (Must be 17 or older to volunteer)

Name
                                                        Address
City
                                                        State                             Zip Code

Day Phone                            Eve Phone                                 Cell Phone

Emergency Contact                                                                         Relationship

Emergency Contact Phone                                          Alternate Phone


Age:          17-30         31-59         60+     E-Mail Address

Gender:         Male          Female              Have you been convicted of a felony or been incarcerated?

 If yes, please explain


Are you a State Employee subject to State Disaster Leave Act?

Are you affiliated with any other Disaster Relief Agencies as a volunteer or paid staff?

If yes, please list Agency(s)                                                 Previous Disaster Relief experience?

Do you have previous Disaster Relief training?

If yes, please explain:


Do you have the following skills:       (check all that apply)    Physician              Nurse         Other Medical Prof.

   Mental Health Professional             Social Worker                Counseling/Spiritual Care           Mass Quantity Food Prep

   Licensed Childcare            Chainsaw Operator                    Secretarial/clerical           Licensed Ham Radio Operator

    Heavy-Equipment Operator                     Licensed Truck Driver                    Security         Warehousing

    Loading/Unloading                Shelter/Lodging                 First Aid           C.E.R.T.


Equipment you have with you available to use:                      Backhoe         Chainsaw          Pickup Truck        Bobcat

   Dump Truck             Passenger Van         Rakes/shovels            Trailer     Tractor: Size


Other Skills / Equipment:

Are you willing to serve at the volunteer reception center?                        Yes       No

   Interviewer              Phone Bank                   Data Entry                 Providing Briefings to Small Groups

Language fluency:                                                Sign Language Capability


Signature __________________________________________________________ Date ___________________________
If you are filling this out electronically, no signature required at the time, signature needed when you respond.