Last Name / First Name / M.I.
Address / City / State / ZIP
Home Phone / Work / Cell / Fax
Email Address / Date of Birth
/ / / Social Security Number
Employer / Job/Title / Driver’s License Number
Do You Have A Medical License?
Y N / License Number / Expiration Date
/ / / State Issued
Do You Have A Health Care Professional License?
Y N / License Type / Expiration Date
/ / / State Issued
Additional Information
Has your driver’s license ever been revoked or suspended?
Y N / If yes, please explain below / Are you licensed to operate a motor vehicle in the state of Illinois?
Y N
Have you ever been convicted of a felony?
Y N / If yes, please explain below
Have you ever been convicted of a misdemeanor, including a DUI, that resulted in imprisonment in the last 24 months?
Y N / If yes, please describe below
Emergency Contact Information
Name: / Name:
Address: / Address:
City, State, Zip / City, State, Zip
Phone Number: / Phone Number:
Relation: / Relation:
Please Check Areas In Which You Are Skilled
Medical
__ Doctor Specialty: ______
__ Nurse Specialty: ______
__ Emergency Medical Professional:
Type:______
__ Pharmacist
__ Pharmacist Technician
__ Veterinarian
__ Veterinarian Technician
__ First Aid (Card expires: ______)
__ CPR (Card expires: ______)
__Triage
Communications:
__CB Or HAM
__Hotline Operator
__Web Page Design
Languages Other Than English
__Spanish
__French
__Sign Language
__Other:______
Office Support
__Receptionist
__Clerical – Filing, Copying
__Data Entry
__Office Equipment (Computers, Fax, etc) / Services
__Language Translation
__Food Preparation
__Elderly/Disabled Assistant
__Child Care
__Spiritual counseling
__Social Work/Mental Health
__Search & Rescue
__Auto Repair/Towing
__Traffic Control
__Security
__Crowd Control
__Animal Rescue
__Animal Care
__Runner/Messenger
__Shelter Management
__Education
__Accounting/Finance
Structural
__Damage Assessment
__Metal Construction
__Wood Construction
__Block Construction
Cert. #:______
__Plumbing
Cert. #:______
__Electrical
Cert. #:______
__Roofing
Cert. #:______/ Transportation
__Mini-Van
__Maxi-Van, capacity______
__ATV
__Own Off-Road Vehicle/4WD
__Own Truck
Type:______
__Own Boat, Capacity______
Type:______
__Snowmobile
__Commercial Driver
Class:______
License:______
__Camper/RV
Type:______
Capacity:______
Labor:
__Loading/Shipping
__Sorting/Packing
__Clean Up
__Equipment Operator
Type: ______
______
______
Equipment:
__Heavy Equipment
__Chainsaw
__Generator
__Other:______
Administrative
__Experience Supervising
__Organizational Skills
Do You Have A Radio License?
Y N / If so please describe below:
List emergency equipment you own:
__Search Lights __Chainsaw __Generator __HAM or CB Radio __OTHER (Please List): ______
List any additional skills/training/knowledge you have that would be of benefit in an emergency situation. (NIMS, ICS, FEMA I.S, etc)
How frequently would you like to volunteer?
__Occasionally __Regularly __Only in an emergency / Are you interested in attending trainings or participating in practice drills? (PARTICIPATION AT A MINIMUM NUMBER OF TRAINIGN’S IS REQUIRED)
__YES __NO
Immunizations Received:
__Tetanus (Date:______) __Smallpox (Date:______)
__Anthrax (Date:______) __Other (Date:______)
Do you have any special considerations or medical restrictions you want to tell us about?
Applicant Verification
- The information provided is complete and true. If information given on this application is incomplete or untrue, I understand my assignment may be terminated.
- I have disclosed any felony convictions. I agree to a background check, verification of the statements contained herein and additional screening procedures. I understand this may include my educational background, references, licenses, police records, and employment history and volunteer history. I also give permission for the holder of any such information to release it to the Henry County Health Department.
- I hold Henry County Health Department harmless of any liability, criminal or civil, which may arise as a result of the release of this information about me. I also hold harmless any individual or organization that provides information to this agency. I understand that Henry County Health Department will use this information only as part of its verification of my volunteer application.
- I understand that my own insurance will be used as coverage for illness and injuries and that I am ultimately responsible for any costs incurred.
- I agree to respect the rights, property, and confidentiality of emergency workers and individual’s affected by a disaster.
- I agree to adhere to the rules/instructions of my job assignment(s) so as not to jeopardize relief operations or procedures.
- I agree to uphold the mission of the health agency in the event of a disaster.
______
SignatureDate
Date Accepted:______MRC Coordinator:______
Date Accepted:______HCHD Administrator:______
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