Pre-register to become a post disaster volunteer in the Suncoast region (Manatee, Sarasota, Charlotte, Hardee and DeSoto counties) of Florida - THANK YOU ! You must be over the age of 18.
This form must be completed fully before submitting. You cannot partially complete, save and return to the form later. Some fields are required.
By completing and submitting this form you are attesting that you are the applicant named on the form and over the age of 18.
Full Name:
*
First Name
Middle Name
Last Name
Birth Date:
*
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Year
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Year round resident?
*
Yes
No
If no, months available:
For example: October to May
Best Phone Number:
*
-
Area Code
Phone Number
Next Best Phone Number:
-
Area Code
Phone Number
Alternate Phone Number:
-
Area Code
Phone Number
E-mail Address:
Occupation:
Employer:
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Employer Phone:
-
Area Code
Phone Number
Education Achieved:
Please Select
High School
College
Post Graduate
Drivers License Number:
Drivers License Issuing State:
Drivers License Expiration Date:
mm/dd/yyyy
Drivers License Type:
if you possess a special license like a CDL
Emergency Contact:
First Name
Last Name
Emergency Contact Relationship:
Emergency Contact Phone Number:
-
Area Code
Phone Number
Emergency Contact Alternate Phone Number:
-
Area Code
Phone Number
If you have any physical or health limitations or you're taking any medications which may impact volunteer activities, please explain below:
Limitations:
I am available for assignment
FROM: (date)
mm/dd/yyyy
TO: (date)
mm/dd/yyyy
Day Availability:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time Availability:
AM
PM
Anytime
Not Sure
Are you currently affiliated with a disaster relief agency?
Yes
No
If Yes, name of agency:
Previous volunteer experience. Include Job title, organization, duties and how long performed.
Current licenses and certifications:
Are you fluent in English?
*
Yes - Fully Fluent
Yes - Speak Only
No
Are you fluent in Spanish?
*
Yes - Fully Fluent
Yes - Bi-Lingual English
Yes - Speak Only
Yes - Read Only
Yes - Able to Translate
No
Any other languages (other than English or Spanish) that you are proficient in? Please enter by the name of the language Read Only, Speak Only, Fluent, Bi-Lingual, or Able to Translate.
For example, Ukrainian-Fully Fluent
SKILLS and SERVICES inventory, please check all that apply to you and that you are willing to perform
MEDICAL: Please check all skills/services that apply. We will refer Indiviudals who check this box to the Medical Reserve Corp.
Doctor (MD, OD, PA, ARNP, etc.) - see question below
Nurse - see question below
Emergency Medical Certification
Veterinarian
Veterinarian Technician
MEDICAL: If Doctor above, specialty
MEDICAL: If Nurse above, specialty
COUNSELING: Please check all skills/services that apply
Mental Health
Social work/casework
Spiritual Care
COMMUNICATIONS: Please check all skills/services that apply
CB Radio
Ham Radio
Telephone Systems
Communications Equipment
Satellite Equipment
STRUCTURAL: Please check all skills/services that apply
Damage Assessment
Construction - Wood
Construction - Metal
Construction - Block/Masonry
Plumbing
Electrical
Mechanical - HVAC
Roofing
LABOR/EQUIPMENT: Please check all skills/services that apply
Warehouse
Logistics
Loading/Shipping
Clean-Up
Operate equipment - see question below
Experience in supervising labor force
LABOR/EQUIPMENT: describe equipment you can operate
ADMIN/OFFICE SUPPORT: Please check all skills/services that apply
Clerical / Copy / Filing
Data Entry
Software Capable - please specify programs below
Invoice Review
Accounting / Bookkeeping
Purchasing / Ordering
Inventory
Receptionist - Telephone / Live
Management / Supervision
IT Skills - Workstation / Server Support
IT Skills - Application / Systems Administration
IT Skills - Networks / Telcom / Security
Public Relations / Promotions
Public Speaking
Writing
Planning / Project Management
Event Planning / Organizing Meetings or Conferences
Photography & Editing
Web Page Design & Site Maintenance
Knowledge of Community & Volunteer Agencies
Knowledge of Government Structure & Process
ADMIN/OFFICE SUPPORT: Software capabilities, please describe programs
INTERPERSONAL SKILLS: Please check all skills/services that apply
Human Resources
Volunteer Mangement
Interviewing
Assessment
Teaching / Training
SERVICES: Please check all skills/services that apply
Food - Cooking
Food - Preparation
Food - Serving
Assist Elderly / Disabled
Child Care
Search & Rescue
Crime Watch
Runner / Courier / Delivery
Animal - Rescue
Animal - Care
Animal - Shelter
Recreation
TRANSPORTATION: Please check all skills/services that apply
Driver
Traffic Control
Auto Repair
Towing
TRANSPORTATION: Please describe any Car, Truck, VAN, Boat, Camper, RV, or ATV that you own that you would be willing to lend or donate
Legal Stuff...
Have you ever been convicted of a misdemeanor or felony?
*
Yes
No
Unsure
If Yes, for what offense and when?
I verify that I have not received any court ordered penalty (e.g. conviction, probation, deferred adjudication, etc.) for a crime within the last 7 years. If any of the information contained in my application is incomplete or found to be unture, I understand that I may be removed from the disaster relief operation and this registery. By click on Yes below I agree with this statement.
I (the applicant named on this form) affirm that the statements above are true and correct.
*
Yes
No
Release of Liability Statement (must be over the age of 18)
I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify and hold harmless the volunteer coordinating agency, Sarasota County Government, the State of Florida, the organizers, sponsors and supervisors of all disaster preparedness, response, mitigation and recovery activities from all liability for any and all risk of damage or bodily injury or death or property damage, including any injury or damage caused by negligence, in connection with any volunteer disaster effort in which I participate or which may arise from my participation in volunteer disaster efforts of from my presence on a worksite or in vehicles as part of said participation. I likewise hold harmless from liability any person or agency transporting me to or from any disaster preparedness, response, mitigation, recovery and relief activities. In addition, disaster relief officials have my permission to utilize any photographs or videos taken of me for publicity or training purposes without compensation paid to me. I will abide by all safety instructions and information provided to me during disaster relief efforts. I understand and agree that failure to abide by such safety instructions and information may result in my immediate dismissal from the Disaster Volunteer Program, without recourse. Further, I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have no known or physical or mental condition that would impair my capability to participate fully, as intended or expected of me. I have carefully read the foregoing release and indemnification and understand the contents thereof and affirm this release below as my own free act.
*
Yes, I am the applicant named on this form and I am over the age of 18, and I agree with the Release of Liability Statement above.
No, I am not or I do not agree.
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