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DISASTER VOLUNTEER INTAKE <br />AND REFERRAL FORM <br />Er: ERGEfVCY <br />CENTEf3 <br />~^ CityatCampbeN <br />'3 City of Cupertino <br />7 City of GBroy <br />^ Cily of dos AStos <br />^ Town c` Lo=_ Al,os Hias <br />down of Los Gatos <br />`^ City of Milpitas <br />fl City of tdorfie Sereno <br />City of Morgan L-LiR <br />fl City of S~+lountain Jiew <br />O Ciy of Ralo Atio <br />fl City of.San .lose <br />^ City ~of $arRa Clara <br />^ City of Saratoga <br />O city of .Sunnyvale <br />^ Gourry of Sarca Clara <br />^ Other <br />PRINT PLEASE <br />Name: First ftifidc~te lrit~ last Dare <br />Street Address <br />t i City State <br /> <br />t Zip Occupation <br />Primary Phone Cep Phone Pager E-mail <br />Drivers License # 1 Class Please list age ' Any Physical Limitations? Are you able to Eft heavy items? <br />{rf Under 18) _ ^ Yes ^ No <br /> If yes, up to how many pounds? <br />Parents must accompany minor to register to volunteer <br />If you are with a group, please specify name <br />Availability: Please indicate when you are available. {Check all boxes that apply.) <br />M T W Thu F Sa Su <br />Morning <br />Afternoon <br />Evening <br />Length of Time available (1 week, 1 month, open) <br />Geographic Area: Please indicate the geographic area(s) where you can volunteer. (Choose all that apply.) <br />^ Central County ^ South County ^ Anywhere in County <br />^ North County ^ West Valley ^ Please specify if only one city <br />Skills: Please indicate the skills you possess or tasks you are qualified/willing to do: (Choose all that apply.) <br /> Disaster Skills Office Skills Peo le Skills Manual Skills <br />^ CERT ' ^ Message Runner ^ Language (specify below) ^ Care 8 Shelter <br />^ Safety Assessment ^ Accounting ^ Child Care ^ Heavy Labor <br /> Medical: First Aid, MD, <br />RN, EMT, NP circle) ^ Answering Phones ^ Animal Care ^ Driver (list classes <br />below) <br /> Shelter Assistant ^ Data Entry ^ Medical ^ Carpent <br />~ Traffic/Crowd Control ^ General Clerical ^ Counselor ^ Plumber <br /> Radio Communications ^ Computer Systems ^ Special Populations (seniors, disabled) ^ Electrician <br />^ HAM Radio License ^ Interviewer/Customer Service ^ Debris Removal <br />~ Other (specify below) ^ Legal ^ Food Prep/Service <br />~.ommun¢y emergency rcesponse i earn <br />Please list licenses, special certifications, languages or specifics indicated above: <br />Special EquipmentNehicleslResources you can offer: <br />Volunteer Signature (if in person): <br />Emergency Contact and Relationship: <br />EVC tnre~viearer. <br />Agerx3r Contact <br />bt32rviieaeer Corsunenis: <br />Data Envy Date` ! f tsy: <br />Volunteer Opportunity Referred Vii <br />Wtnte cnl~' - Vot~txrteer Center of Silicon Valley <br />Yepow copy - Lacaf t~rce o€ Emergen~~ Services <br />Pink copy - Volunteer <br />fEVC Farm Q1121]OS <br />Attachment B <br />