5920 FM 2920  |  Spring, TX 77388  |  (281)353-8202  |  Fax: (281)353-5073

KUMC Emergency Preparedness Volunteer Form

Last Name: First Name:

Home Address:

street:
city:    
zip:     

Home Phone:  Cell Phone:

Occupation:

Email Address:

Do You Communicate with Facebook? Y N Twitter? Y N

Person to notify in an emergency:

Name:  Email Address:  

Relationship:

Address:  

Phone:   Cell Phone: 

I would like to work in the following area(s): Please give first, second, and third choice.
See Job descriptions here.

1st   2nd  3rd

Days and Hours Available: (Please mark appropriate day/time)

Mon  Tues  Weds  Thurs  Fri  Sat  Sun

Prior work in emergency relief? Y N  If yes when and what disaster:

Certified in First Aid? Y N                  CPR? Y  N

Driver's License #       State:

Subdivision/Area Where You Live:

Approx. distance from the church             

Are you: Under 18 yrs old?:  18-24 yrs old:   25 or older:

Languages? (Other than English)

Special Skills:

List Microsoft Office Suite Skills: (ex: excel, word...etc)

Will you commit to be one of the first called to open the kitchen? Y N

I verify that I have not been convicted of a felony or, within the last 24 months, been convicted of a misdemeanor that resulted in imprisonment. If this statement is incomplete or untrue, I understand my assignment will be terminated. I have read the fundamental priciples of the Red Cross movement and Standards of Conduct for Disaster Relief workers (here) and agree to abide by them during my assignment with the Red Cross Shelter. If this statement is incomplete or untrue, I understand my assignment will be terminated.

I agree
Disagree