Jo Daviess County

Name:*

Address*

City*

State*

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

Do you speak any language other than English?*

Yes

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

If yes, please indicate which programs*

Do you know how to operate office machines? (Copier, fax, etc.)*

Yes

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

Please indicate the skills you possess or tasks for which you feel both qualified and comfortable. Disaster skills*

Safety assessment

Medical

Security

Traffic control

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*