Disaster Volunteer Application

Elkhorn Logan Valley Public Health Dept

Disaster Volunteer Program
Click submit to register

Or you can email melanie@elvphd.org for a copy of this form to fill out
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email address (required)
Is the phone number you listed a mobile phone that can receive text messages?

YesNoIt is a land line
Place of employment
Occupation
Work phone
Date of Birth

MonthDayYear
Date
Mark any roles you would be willing to fill at a COVID vaccination clinic

Greeter--greet volunteers, help with registration paperwork, answer paperwork questions, manage waiting volunteersVisitor Assistant--assist visitors to the POD as they enter the facility, opening doors, helping them fill out the paperwork, point them in the right direction, answer general questions about the dispensing operationNurse Assistant/Runner--help the nurses with bandaids and time stickers, retrieve items the nurses may need, deliver paperwork to data entry staffParking and Outdoor Direction--help drivers navigate the parking and entry issues coming into the building or vaccine siteOther
Volunteer Skills--check all that apply

Amateur Radio OperatorBus/Truck driver--current CDL licenseBus/Truck driver--expired CDL licenseCPR certified (currently certified)Administration/Office SkillsBasic setup and clean up skillsData entryComputer skills--spreadsheets, Word, etc.IT assistance--able to troubleshoot and fix electronic and computer issuesInterpretation (Spanish or other language)Security
Other Skills

Mental health therapist or counselorSocial workerPsychologist/psychiatristDentistDental hygienistEMTAdvanced EMTParamedicFirefighterPhysician or physician assistantNurse, APRN, etc.Licensed Medication AidePharmacistPharmacy technicianVeterinarian
Licensure

If you are legally able to give vaccines and are willing to do so, we will have additional questions for you and will contact you regarding this.
Have you ever been convicted of a felony?

YesNo
Emergency Contact--Who can we contact on your behalf in case of an emergency?

Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number
Please enter a valid phone number.
By signing my name below, I hereby certify, to the best of my knowledge, the information I have provided is accurate. I am providing my contact information to be kept confidential in the volunteer database. This database will be used during the COVID pandemic response and for future disasters or to promote community preparedness. I acknowledge that health department staff may need to contact me periodically to maintain the accuracy of this information, inform me of training opportunities, or test the effectiveness of ELVPHD's communication plan. I authorize health department staff to contact me or my emergency contact listed above via the contact methods listed. I agree to release Elkhorn Logan Valley Public Health Department from liability arising from any volunteer service I may perform. I also authorize ELVPHD to conduct a background check on me with the information I have provided. I authorize ELVPHD to photograph/video me/my child/ren during my/their volunteer service and utilize the image(s) for publishing and /or distribution.
First Name Last Name Signature Date
Should be Empty:

Elkhorn Logan Valley Public Health Dept

Click submit to register

Licensure