Disaster Volunteer Resource Center

How To Enlist

Sign on in advance to help in times of disaster. Tell us how to get in touch with you:
Name:
Date of Birth:
Address:
City:
State:		Zip:
Phone Day:		Fax:
Phone Evening:		Cell:
E-mail:

Skills / Profession/Areas of Interest
(Check appropriate categories and any special skills for category)
Note: If license/certification is required, you must provide it upon request.

	Administration/Supervision
	Animal Care
	Animal Rescue
	CDL
	Bus Driver Trucker
	Child Care
	Communications
	Ham Radio/CB Radio Cellular Phones Other
	Computer Skills
	Computer Operation Computer Repair/Installation Data Entry Other
	Construction/Repair
	Home Repair Welding Other
	Counseling
	School Counselor Clergy Licensed Mental Health Practitioner Psychiatrist Psychological First-Aid Other
	Damage Assessment
	Debris Removal/Clean-Up
	Driving
	EMT/Fire & Rescue
	Farmer

	Food Service
	Food Preparation Food Management Other
	General Office Skills
	Heavy Equipment Operator
	Fork Lift Other
	Languages
	Spanish (SpeakReadUnderstand) Neur (SpeakReadUnderstand) Sign Other
	Law Enforcement
	Mechanical Ability
	Medical/Veterinary
	Dentist Paramedic Lab Tech/MTLPN Physician RN NP Veterinarian PA X-Ray Technician Other
	Missing Person Search
	Mortuary Service
	Security Experience
	Shelter Services
	Special Populations
	Seniors
	Disabled Other
	Teacher
	Waste Disposal
	Other

When Available:

Days:

Evenings:

Nights:

M	T	W	Th	F	S	Su

Length of time available (1 week, 1 month, open)


I prefer to be:		Inactive (prepared for service only in an emergency or disaster)
		Active (leader, recruiter, trainer, community health initiatives, etc.)

Where Available:	Boone	Colfax	Platte	All of Nebraska
	Butler	Nance	Polk	Other

Special Requirements:	Sitter for Children
	Disabilities
	Other

Restrictions:

Date of Last Tetanus Shot:

I hereby make application to become a disaster response volunteer in the area. I also hereby give permission for this information to be shared exclusively between the Columbus Area United Way, East-Central District Health Department, Platte County Emergency Management and the Prairie Valley Chapter of the American Red Cross.
Initial for Signature:	Date:

Volunteering is a reward everyone deserves – enlist now to discover yours!