Fillable Form 1: Volunteer Application for Emergency Operations Center, (Essex Town Hall)

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Form 1: Volunteer Application for Emergency Operations Center, (Essex Town Hall)

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The Form 1: Volunteer Application for Emergency Operations Center, (Essex Town Hall) form is 4 pages long and contains:

  • 2 signatures
  • 39 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

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Volunteer Application for Emergency Operations Center, Town of Essex
Page
1
TOWN OF ESSEX
VOLUNTEER REGISTRATION
FOR EMERGENCY OPERATIONS CENTER
Date of Application
Date Available to Volunteer:
Last Name:
First Name:
Street Address:
Cell Phone:
Home Phone:
City/State/ Zip:
Email Address:
Driver’s License Number: (Please provide a copy)
Do you have transportation to Emergency Site?
Yes/No
Military Status: Active/Reserve/Retired or N/A
Do you have any Emergency Management
Volunteer Experience? Yes/No
Skills / Training / Abilities
Call Center
Case Work/Social Services
Children (Formal Child Care Training)
Communications
Construction
First Responder Trained*
Food Services*
Heavy Lifting (>30 lbs)
Laborer
Logistical Support
Medical* (DR/Nurse : Active / Retired)
Medical* (EMT)
Medical* (Other) _________________________
Moving the Elderly / Disabled
Ministry / Pastoral Care Officer Clerical
Personnel/Volunteer Managment
Transportation*
Veterinarian/Veterinarian Technician*
*Please provide copy of license/certification
Emergency/Disaster Related Training/Certifications
Call Center
CERT
CPR
First Aid
AED
Red Cross
Search / Rescue
Shelter Operations
Radio Call (Ham _________ / GMRS ________)
FEMA – Emergency Management Institute,
Independent Study Programs.
IS-100.B – Introduction to Incident Command*
System ICS-100
IS-200.B – Introduction to Incident Command*
System ICS-200
IS-700.B – Introduction to Incident Command*
System ICS-700
IS-800.B – Introduction to Incident Command*
System ICS-800
Volunteer Application for Emergency Operations Center, Town of Essex
Page
2
CURRENT EMPLOYER
Employer Name and Address:
Job Title:
Phone:
Will you be permitted to leave your place of employment when called to respond to an emergency without
penalty? YES / NO
Will you require a Notice to Employer of your Emergency Volunteer Status for the Town? YES / NO
Have you ever worked for the Town of Essex or Region 4 Schools in any capacity? YES / NO
Have you ever been convicted of a felony?
If yes, please specify (crime, date, location)
Notice: You are not required to disclose the existence of any arrest, criminal charge or conviction, the
records of which have been erased pursuant to CT State law or the law of another jurisdiction. If your
criminal records have been erased pursuant to one of these statutes, you may represent that you have never
been arrested.
_______________________________________________________________________________________
The Town of Essex EOC is a public safety function, background checks are performed. Do you object to a
background check? YES / NO
I certify that the answers given herein are true and complete to the best of my knowledge.
Signature: _________________________________________ Date _______________________
Printed Name: _____________________________________
I authorize investigation of all statements contained in this volunteer registration as may be necessary.
I understand also, that as a volunteer, I am required to abide by all rules and regulations of the Emergency
Management Office for the Town of Essex.
Please return this Registration form to: First Selectman’s Office
EEV Volunteer Coordinator
Town of Essex
29 West Avenue, Essex, CT 06426
_______________________________________________________________________________________
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Volunteer Application for Emergency Operations Center, Town of Essex
Page
3
For Town Use Only
Date Received: __________________________________________
Reviewed By: __________________________________________________
Copy of driver’s license Rcvd: Y/N
Copies of licenses/certifications Rcvd: Y/N
Background Check Released: Y/N
Background Check Completed as of: _________________________
mm / dd / yy
Date Registration Approved _________________________________
Volunteer ID: ____________________________________________
Volunteer Application for Emergency Operations Center, Town of Essex
Page
4
Town of Essex -Emergency Operations Volunteer
Background Check – Release & Disclaimer
I, ______________________________________________________________ am providing information to
be registered as a volunteer with the Town of Essex Operations Center. A background check may be
conducted as part of the formal review process. I therefore, authorize any governmental entity or part thereof
corporation, company, institution or agency and employees in their responsive capacity or individually
without exception to furnish upon request to the Town of Essex Emergency Operations Center or their
authorized representative, any and all information, documentation or otherwise pertaining to me.
I do hereby release the Town of Essex and its employees and representatives in their representative capacity
or individually, from any liability whatsoever incurred from furnishing such information. A photocopied
copy of this authorization will be considered as effective and valid as the original.
Signature ________________________________________ Date: _________________________
Printed Name _____________________________________
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Form 1: Volunteer Application for Emergency Operations Center, (Essex Town Hall)

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Completed 21 January 2021

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