Home Departments Health Emergency Preparedness Public Health Emergency Volunteer Application Public Health Emergency Volunteer Application Edit Form Name:* Address* City* State* Alabama Alaska Arizona Zip* Home Phone Number* Cell Phone Number* Email Address* Special training, license or certifications (e.g. RN, LPN, MD, CPR, Ham radio operator, etc.)* Are you a licensed driver?* Yes No Do you speak any language other than English?* Yes No If yes, please specify* Please list any skills or previous experience you have that would be helpful.* Do you know how to operate a computer?* Yes No If yes, please indicate which programs* Do you know how to operate office machines? (Copier, fax, etc.)* Yes No If yes, please explain Person to notify in case of emergency* Address* Relationship* Phone Number* Alternate Phone Number* I hereby certify the information I have supplied above is true and accurate, that I am freely volunteering for such duty without coercion or duress, and that I am mentally and physically fit for service. I understand the information that I have supplied may be disclosed for security reasons. I understand that I may be assigned to a variety of duties, but that every reasonable effort will be made to find a good match with my interests and skills. Finally, I understand this is a totally volunteer effort and I will not be paid for my services. *Acknowlege* Yes No Please indicate the skills you possess or tasks for which you feel both qualified and comfortable. Disaster skills* Safety assessment Medical Security Traffic control Office skills* Message runner Answering phones Data entry Accounting General clerical People skills* Child care Animal care Medical Customer service Special populations Manual skills* Care & shelter Heavy labor Driver Food prep/service Skilled trade Other - Please indicate any other particular skills you possess* Describe any restrictions on your activites (physical, medical, mental)* What are you most interested in doing?* What new skills would you like to learn?* Any additional comments*