Volunteer Registration

Last Name

First Name

Home Phone

Work Phone

Address

City

State

Zip

Are you currently?

Employed

Retired

Unemployed

If employed, what city?

I am interested in volunteering on:

Regular Basis

Emergency Only

Other (please enter)

What days or hours are you most available, in the event of a disaster?

In the event of a disaster, is there another phone number, pager number, or contact person we could reach you by, should we be unable to contact you with the above information?

Depending upon the extent of the potential disaster, we may have treatment sites at a variety of locations throughout the county. Please rank these areas in your order of preference to volunteer (1 being most desirable, 5 being least desirable).

	Point Pleasant
	Gallipolis Ferry
	Mason
	Ashton
	New Haven

Do you anticipate that you would have child care needs?

Yes

Which of these volunteer positions would best suit your abilities?

(Please check all that apply)	RN	LPN	Medical Staff
	Security	Traffic Control	Mental Health
	Data Entry	Supply Clerk	Translator
	Custodial	Float Staff	Special Needs
	Registration	Food Service	Pharmacy
	Office Help	MIS

If Medical Staff selected, then list certification/licensure:

Do you have any other special concerns or questions?

If you are finished, then please click submit