Please complete this application form if you are interested in becoming a COVID Eau Claire County Volunteer. Once you complete the form, click the Continue button at the bottom. If you have questions pertaining to the application please email covidvolunteerecc@gmail.com


Name and address


Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.



Driver's License #


Health Information


Emergency Contact

Please provide at least 1 emergency contact name and phone number.



Email Notifications

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email.



Release of Liability Statement

I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless the Volunteer Reception Center, the Northwest WI Healthcare Coalition and those under their direction, local municipality governments, the State of Wisconsin, the organizers, volunteer team leaders, homeowners and fellow volunteers of all emergency 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 an volunteer emergency effort in which I participate. I likewise hold harmless from liability any person transporting me to or from any emergency response activity. In addition, emergency response officials have permission to utilize any photographs or videos taken of me for publicity or training purposes. I will abide by all safety instructions and information provided to me during emergency response efforts.


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


I have no known physical or mental condition 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 acknowledge this release as my own free act by checking "I agree" below.