Volunteer Disaster Registration

NOTE: THIS APPLICATION IS RESERVED FOR COMPLETION IN THE INTEREST OF DISASTER RESPONSE/RECOVERY ACTIVITIES.

THANK YOU for your interest in assisting with disaster response/recovery.

Complete the information below to assist us with matching you to an assignment that aligns with your skills and interests as they become available.

Name and Contact Information

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Fax phone:

Email address:

Date of birth:

Gender:

Education:

Ethnicity:

Aliases:

Group Volunteer Registration

If you are part of a non-disaster response group that wishes to volunteer (i.e. Haines City Rotary Club, The employees of ABC Retail, etc.), please include your group name and city/state.

Group name:

Members:

Participation:

If your group will serve more than once, you will usually send...
The same volunteers each time
Different volunteers each time

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Availability and Location

Please indicate the days and times you are usually available to volunteer.

Skills: Please check all that apply.

Emergency Contact

In case of emergency who is your primary emergency contact?

First name:

Last name:

Nickname:

Home phone:

Work phone:

Cell phone:

Relationship:

RSVP Enrolled Volunteers ONLY

If you are age 55 or older, are you currently enrolled in RSVP Polk? (Michelle Shiver)

RSVP Enrolled:

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