Volunteer Form | Marion County Health Department

Volunteer Information

First Name

Last Name

Email

Primary Phone

Secondary Phone

Fax

Number of Household Members (including yourself)

Street Address

City

State

Zip Code

Current Employment

Are you currently employed?

Yes

No

Employer

Length of Employment

Business Phone

Position/Title

Business Address

City

State

Zip Code

Experience

Organization

Phone

Dates Employed

Supervisor Name & Title

Business Address

City

State

Zip Code

Organization

Phone

Dates Employed

Supervisor Name & Title

Business Address

City

State

Zip Code

Prior or Current Volunteer Experience

Current License(s)

License Type

License Number

State

Expiration Date

License Type

License Number

State

Expiration Date

Language Skills

Describe fluency in languages other than English, include sign language:

Volunteer Opportunities

Registered with other volunteer services?

Yes

No

If Yes, please list:

Prior Disaster Relief experience?

Yes

No

If Yes, please list:

Activities which interest you or skills you possess (select all that apply):

Availability

Daily availability (select all that apply):

Duty Preference

Prefer continuous duty

Prefer duty on separate days

No preference

Are you willing to deploy outside of the local jurisdiction?

Yes

No

Describe hours available:

Emergency Contact Information

First Name

Last Name

Relationship

(spouse, sibling, parent, friend, etc)

Primary Phone

Secondary Phone

First Name

Last Name

Relationship

(spouse, sibling, parent, friend, etc)

Primary Phone

Secondary Phone

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?

Yes

No

Are you currently charged with or have you ever been convicted of a felony?

Yes

No

If Yes, please explain: