Southeast Region Public Health Emergency Volunteer Application

This application is to identify volunteers interested in assisting in emergency response in your county. It has been determined that several hundred volunteers are needed to respond to public health emergencies in our community. If interested in participating, please complete this application.

First Name		Last Name
Profession
Address		City
Zip code		Day Telephone
Date of birth		Night Telephone
Counties in which you are willing to volunteer	CassRichlandSteele RansomSargentTraill	Email
Preferred method of contact	EmailPostal Mail

Background Information 
It is imperative that security be provided as part of the emergency response process.

YesNo		Have you been convicted of a felony or misdemeanor? If yes, please identify offense and date.
YesNo		Have you had a criminal background check?
YesNo		I consent to a Criminal Background Check by the appropriate law enforcement agency. (Volunteers may be handling/working with medical/vaccine products.)
YesNo		All PHEVR-MRC volunteers must provide a social security number for insurance purposes and background checks. Are you willing to provide this information?

In order to facilitate processing of the applicants and program elements needed, please check the desired area of your expertise and/or program element in which you would like to volunteer.
(Please mark all categories of interest)

Medical volunteer skills:
Triage (Nurse/EMT)Medical Screeners
EducatorPhysician Evaluators (Evaluate ill/additional screenings)
Vaccinator/Medicine DispenserEMT

Non-medical volunteer skills:
Information DistributorLogistics/Supplies
Data EntryCrowd/Traffic Control
SecurityInterpreters (Language)
General Volunteer AssistanceTechnology Support