Lenawee County Emergency Management Volunteer Registry
I understand that by completing this form, I will be subject to a background check.
*
Yes, I understand
Name
*
First Name
Last Name
Organization (If applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth (for background check purposes)
*
-
Month
-
Day
Year
Date
Gender (for background check purposes)
Please Select
Female
Male
Race (for background check purposes)
Please Select
American Indian or Alaskan native
Asian or Pacific Islander
Black
White
Other
I decline
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Emergency Contact Information
In the event of an emergency while you are deployed to assist.
Relationship
Please Select
Parent
Spouse
Child
Sibling
Another relative
Friend
Co-worker
Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
What is your occupation type?
*
Please Select
Medical
Non-medical
If Medical, choose the best option
Please Select
Administration
Assistant
Chiropractor
Emergency Medical Services
Mental Health
Nursing
Pharmacy
Physical Health
Physician
Specialist
Student
Other Health/Medical
Professional Status (Medical)
Please Select
Licensed/Certified and Active
Licensed/Certified Part-Time
Licensed/Certified and Inactive less than 5 years
Licensed/Certified and inactive more than 5 years
Non-Licensed/Certified
If Non-medical, choose the best option
Please Select
Administrative Support
Child Care
Clerical
Construction
General Labor
General Logistics
Heavy Equipment
Interpreter
Security
Professional Status (Non-Medical)
Please Select
Active
Inactive
Retired
Student
Language (Indicate other than English, that you are able to speak or write)
Please Select
Spanish
Other
If Other language, please specify below
Spoken ability
Basic
Conversational
Fluent
Written ability
Basic
Conversational
Fluent
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Volunteer - Willingness and Availability
*
Weekdays
Weeknights
Weekend days
Weekend nights
Anytime
Volunteer Activity Preferences
*
Within my Profession
Clerical
General Labor
General Logistics
Flexible as needed
I understand that by clicking "submit," I will be subject to a background check
*
Agree
I understand that Lenawee County has a legal and ethical responsibility to maintain client privacy, including obligations to protect the confidentiality of client information and to safeguard the privacy of client information including, but not limited to, client medical records and other individually identifiable health information. In addition, I understand that during the course of my employment/assignment/affiliation with Lenawee County, I may see or hear other confidential information such as a client's financial data and/or operational information pertaining to the organization that Lenawee County is obligated to maintain as confidential. My submission below acknowledges that I have read and understand the Lenawee County Confidentiality Policy for Employees and Non-Employees and that I agree to abide by the terms outlined in this POLICY.
*
I agree
If you have any questions, please email:
jeff.betz@lenawee.mi.us
Submit
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