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.