Emergency Prep Registration

Your occupation, hobby, interest, or vocation may be just what your community needs during a disaster. If you are willing to share your knowledge, experience and expertise with those in your community, please complete the registration form below. The information you enter will be stored in a database. Should a disaster occur and a need arise that you can fill you may be contacted and asked to assist.

More Emergency Preparedness Topics

Personal Information

Last Name: First Name:

Home Address:

Home Phone: Alternate Phone:

E-mail address:

Occupation:

Name of employer:

1. Are you a Certified Disaster Service Worker?

No Yes OES Number:

2. Are you currently certified in any of the following areas?

CPR	AED	First Aid	Lifeguard	Mass Care/ Sheltering
Other certifications:

3. Do you possess skill or hold a license in any of the following areas?

Sign Language Social Work/ Counseling Pilot

Bus Driver Heavy Equipment Op. Semi-truck Driver

Emergency Medical Tech. Telephone Operator Dispatcher

Medicine Animal Care/Medicine Pastoral Care

Catering/Food Service Child Care Elder Care

Disability Care Construction Amature Radio

Other licenses/skills you possess:

4. Please list below any additional talents, skills and abilities you possess and wish to share with this community:

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