Carbon County Emergency & Disaster Volunteer Registration Form
Carbon County is building a network of individuals of all capacities to volunteer to be on a local list maintained by Carbon County. If you are willing to be contacted to participate (when available) during Public Health Emergencies, Disaster Emergency Preparedness and events including trainings and exercises, and other urgent county needs please fill out this form and submit. Volunteers may be asked to perform tasks that are within their scope of practice, from assisting in registration and information gathering, to patient/traffic flow, to administering vaccinations & medications, to logistical support (access and certification to operate equipment), Technical Support (IT assistance etc.) Those with license are asked to upload a copy of their license (Medical licenses, certifications, legal documentation of abilities etc.) All information is kept confidential and is HIPAA Compliant.
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
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Emergency Contact
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First Name
Last Name
Emergency Contacts Phone Number
*
Please enter a valid phone number.
May we text and email you when there is an incident or event that we are seeking help for?
Yes, you may text and email me
No you may not text, but you may email me
Do you hold a professional Healthcare License?
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Yes
No
What are your healthcare licensures/certifications?
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Registered Nurse
Mid Level Provider
Licensed Provider
EMT
Advanced EMT
Paramedic
Mental Health Professional
N/A - I Have a different certification & will put it in the comments box
Respiratory Therapy
Medical Assistant
CNA
Take a picture or upload a copy of your professional health license
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Any Special Comments **OPTIONAL**
Do you hold any other form of specific training or licensure that is non medical related?
(Heavy Equipment Operator, Chef/Meal Preparation, Computer Programing, Construction, Accounting, Public Information Officer certification, Engineering, Web Development and Design, Computers and information technology (IT), Secretary experience, Data Analysis, etc.) Please try to be as specific as you can.
Other specific training, licensures, certifications etc.
*
Accounting/Financial Management
Public Information Officer Certification
Engineering
Web Development & Design
Computers & Information Technology
Secretary Experience
Data Analysis
Heavy Equipment Operator
Legal
Event Organization & Community Organization
Education & Instruction
Wildlife Conservation
Patient Navigation
Senior Care Assistance with routine tasks
Senior Social & Emotional Wellness visiting
Commercial food preparation and storage
None
Other - Please explain in the comments box
Other training, experience, licensures, skills, etc. Please try to be as specific as you can in the box below - this assists us in paring up volunteers appropriately in their areas of specialty and abilities to assist.
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Signature
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