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