ACS-DR Volunteer Interest Form : Video Training Website Lincoln NE

Email

Phone Number

Age

Home Church

Home Conference

Occupation

Employer

Emergency Relationship

Emergency Phone Number

When are you available and for how long? Indicate availability on weekends and/or weekdays.

List special skills, vocational and/or disaster training. Include any previous experience.

If you are affiliated with a disaster relief agency, please provide the agency name.

Areas of Volunteer Interest MEDICAL (doctor, nurse, emergency medical technician, mental health counseling, veterinarian, veterinary technician). COMMUNICATIONS (CB/Ham operator, hotline operator, public relations, spokesperson, crisis communication, web site management, sky phone user, cell phone owner). LANGUAGE (Russian, Spanish, Korean, French, German, other) SERVICE (food, elderly/disabled assistance, childcare, spiritual counseling, social work, search and rescue, auto repair/towing, traffic control, crime watch, animal rescue, animal care, runner). HOUSING TO SHARE (for victims, for other volunteers): camper, mobile home, house, apartment. TRANSPORTATION (car, station wagon, mini van, maxi-van, ATV, off-road vehicle/4WD, boat; commercial class driver). OFFICE-CLERICAL (filing, copying, data entry, phone reception, computer support, inventory). LABOR (loading/shipping, sorting/packing, clean-up, operate equipment, supervise others, building). EQUIPMENT (heavy equipment, chain saw, forklift, generator, other). OTHER (disaster response leadership, disaster response liaison, warehousing/collection center/distribution center, disaster response instructor, other).

Any additional details on your interest areas?

What further training would you like to receive?

I have seen what can happen when disaster strikes and I want to not only be prepared for myself and my family, but I want to help others in time of disaster in a meaningful and organized way. Count me in. I commit myself to become trained, prepared and ready to help. I will make myself available when disaster strikes and will commit one or two weeks per year (or as needed) for response to disasters as part of an organized team in my conference. One Week Two Weeks As Needed

I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless Adventist Community Services Disaster Response, 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.

Yes No

I likewise hold harmless from liability any person transporting me to or from any disaster relief activity.

Yes No

In addition, disaster relief officials have permission to utilize any photographs or videos taken of me for publicity or training purposes. Untitled

Yes No

I will abide by all safety instructions and information provided to me during disaster relief efforts.

Yes No

Further, I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the State and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Yes No

I have not known physical or mental conditions 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 (electronically) as my own free act.

Yes No

Date

Video Training Website

Living Generously, Sharing Faithfully

ACS-DR Volunteer Interest Form

Volunteer Interest Form

Current Employment

Emergency Contact

Availability, Skills & Interests

Commitment

Release of Liability

Digital Signature

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