Disaster Response Volunteer Intake Form

Spartanburg County Office of Emergency Management

VOLUNTEER REGISTRATION FORM

Name:
Street Address:
City
State
Zip:
Mailing Address (if different)
Home Phone:
Work Phone
Mobile Phone:
Fax:
Date of Birth:
Email Address:
Occupation
Agency Name:
Languages Spoken (other than English)	Spanish French German Russian Chinese Japanese Other (Explain Below)
Affiliation with Volunteer Agency or University/College:	American Red Cross CERT Church Related Disaster Response (Explain Below) Congregational Nursing Converse College Mental Health Mobile Meals Salvation Army Spartanburg Community College Spartanburg Methodist College United Way USCU Wofford College Other (Explain Below)
General Skill Sets:	Administration Office Skills Basic Clean-up Skills Mechanical Ability Food Preparation Customer Relations Waste Disposal Bus/Truck Driver (w/Valid CDL License) Computer Skills Landscaping Interpreter Skills Construction/Heavy Equipment Elderly Care Special Needs (hearing, seeing) Physically Disabled Child Care Mentally Challenged Prisoner Care Animal Care/Rescue Carpentry
Counseling: Please check license(s) below	Alcohol and Drug Counselor Mental Health Practitioner Master Social Worker Professional Counselor Social Worker Marriage/Family Therapist Psychiatrist Psychologist
Medical: Please check license(s) below	Medical Doctor Physician Physician Assistant Nurse Practitioner Registered Nurse LPN Chiropractor Other (Explain Below)
Disaster Related Training:	AHA - First Aid/COR American Red Cross - First Aid/CPR CERT CB Radio Clergy Critical Incident Stress Management (Basic) Critical Incident Stress Management (Advanced) EMT Basic EMT Intermediate EMT Paramedic Emergency Communications HAM Radio FEMA IS100 FEMA IS200 FEMA IS700 FEMA IS800 First Responder Law Enforcement Other (Explain Below)
Emergency Volunteer Center(s) - Staff: Please Mark ANY roles you are willing to work at an EVC if selected to do so:	Date Entry - Enter volunteer registration and Agency Requests for volunteers in database and create reports as needed Greeter - Greet volunteers, oversee registration paperwork and answer questions related to paperwork, manage waiting volunteers Interviewer - Discuss completed registration forms with volunteers, determine their skills, interests and abilities, assign them to disaster recovery agency Phone Bank Staff - Receive agency volunteer requests and calls from potential volunteers Safety Orientation - provide new volunteers with a prepared safety orientation as well as update them on current emergency activities. Runner - Keep stations supplied, carry information from station to station, escort volunteers to various stations
Have you ever been convicted of a Felony:	Yes No
Emergency Contact: (Provide Name, Relationship, and Contact Info)
Other Information We Need to Know (if you selected "Other" above, please fill in the appropriate information)
Prior to Submitting this Form, I agree with the following Statements:
Release of Information Statement I am providing my contact information to be part of a confidential database, maintained by the Spartanburg County Office of Emergency Management, to be used in the event of an emergency. To the best of my knowledge, the information provided in this document is accurate and true. I acknowledge that Emergency Management may need to contact me periodically to maintain the accuracy of this information, or to test their communication plan’s effectiveness. I authorize the Spartanburg County Office of Emergency Management to contact me, utilizing any or all methods of communication, should the need arise.
Release of Liability Statement I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless the organizers, sponsors and supervisors of all disaster preparedness, response and recovery activities from all liability for any and all risk of damage or bodily injury or death that may occur to me (including any injury caused by negligence), in connection with any volunteer disaster effort in which I participate. I likewise hold harmless from liability any person transporting me to or from any disaster relief activity. In addition, disaster relief officials have permission to utilize any photographs or videos taken of me for publicity or training purposes. I will abide by all safety instructions and information provided to me during disaster relief efforts. Further, I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the State of South Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have no known physical or mental condition that would impair my capability to participate fully, as intended or expected of me. I have carefully read the foregoing release and indemnification and understand the contents thereof and sign this release as my own free act.