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Grant County Emergency Volunteer Application

2. First Name

3. Last Name

5. Are you a previous Emergency Operations Center (EOC) volunteer?

   1. Yes

   1. No

7. Do you have previous Incident Command System (ICS) course work?

   1. Yes

   1. No

9. List Completed Courses

11. Are you a current Community Emergency Response Team (CERT) member?

    1. Yes

    1. No

13. Which CERT do you belong to?

15. Email

16. Cell Phone

18. Home Phone

20. Address

22. City

23. State

24. Zip

26. Emergency Contact Name

28. Emergency Contact Relation

30. Emergency Contact Phone Number

32. What volunteer areas interest you?

    1. Evacuation Support
    2. Emergency Office Support
    3. Emergency Operations Center Support

    1. Emergency Shelter Worker
    2. Public Education and Community Outreach
    3. Sand Bagging Operations

    Training will be provided for all areas.

34. What special skills or qualifications do you have as a volunteer?

36. Do you have any language skills?

    1. Yes

    1. No

38. What language(s) are you proficient in?

40. How did you hear about the Grant County Emergency Volunteer Program?

    1. Internet
    2. Newspaper
    3. Public Education and Outreach

    1. Radio
    2. Other

42. Agreement and Signature

    By submitting this application I affirm that the information provided are true and complete.

    1. I agree
44. Applicant Digital Signature

45. Date
    Date

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field