Marion County, Illinois
Public Health Emergency
Volunteer Application
~Volunteer Information
LAST NAME
FIRST NAME
MIDDLE
MAILING ADDRESS
CITY
PHONE #1
PHONE #2
FAX NUMBER
EMAIL ADDRESS
NUMBER OF FAMILY MEMBERS IN YOUR
HOUSEHOLD (INCLUDING YOURSELF):
~Current Employment
EMPLOYER
Not employed at this time.
LENGTH OF
EMPLOYMENT
POSITION / TITLE
BUSINESS ADDRESS
CITY
BUSINESS PHONE
~Experience
ORGANIZATION NAME
ADDRESS
PHONE
DATES EMPLOYED
TO
SUPERVISOR'S NAME / TITLE
ORGANIZATION NAME
ADDRESS
PHONE
DATES EMPLOYED
TO
SUPERVISOR'S NAME / TITLE
PRIOR OR CURRENT
VOLUNTEER EXPERIENCE:
~Current License(s)
TYPE OF LICENSE
LICENCE NUMBER
STATE
EXPIRATION DATE
TYPE OF LICENSE
LICENCE NUMBER
EXPIRATION DATE
STATE
~Language Skills (fluency in languages other than English, include sign language):
~Volunteer Opportunities
No
Yes     If yes, please list:
ARE YOU REGISTERED WITH ANY
OTHER VOLUNTEER SERVICES?
No
Yes     If yes, please list:
DO YOU HAVE PRIOR DISASTER
RELIEF EXPERIENCE?
CHECK ACTIVITIES WHICH
INTEREST YOU OR
SKILLS YOU POSSESS
(CHECK ALL THAT APPLY):
Clerical
Public Information Assistant
Communications
Disaster Education
Planning Assistant
Language Translator
Safety
Medical
Information Technology
Other
~Availability
Tuesday
Anytime
Monday
Wednesday
Sunday
Saturday
Friday
Thursday
Prefer duty on separate days
Prefer continuous duty
HOURS AVAILABLE:
Are you willing to deploy outside of the local jurisdiction?          
Yes           
  
No
~Emergency Contact Information
NAME
RELATIONSHIP
(spouse, sibling, parent, friend, etc)
PHONE #1
PHONE #2
NAME
RELATIONSHIP
(spouse, sibling, parent, friend, etc)
PHONE #1
PHONE #2
~Medical Information
DESCRIBE ANY RESTRICTIONS ON YOUR ACTIVITIES (PHYSICAL, MEDICAL, MENTAL);
DATE OF LAST TETANUS SHOT:
~Personal Information
ARE YOU LICENSED TO OPERATE A
MOTOR VEHICLE IN THIS STATE:
No
Yes
ARE YOU CURRENTLY CHARGED
WITH OR HAVE YOU EVER BEEN
CONVICTED OF A FELONY?
No
Yes     If yes, please explain: