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* 1. Personal Information

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* 2. Personal Information

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* 3. GENDER:

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* 4. Emergency Volunteer Center (EVC) Roles: Each county, depending on the scale of a disaster, may set up an EVC to process additional volunteers. Please mark ANY roles in which you are willing to work at an EVC.

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* 5. Volunteer Skills: Please check all that apply.
General Skills

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* 6. Nebraska Licenses or Certifications: Please check all that apply.

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* 7. Has your professional license ever been suspended, revoked, or disciplined?

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* 8. Training: Please indicate all disaster or emergency-related trainings that apply.

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* 9. Have you ever been convicted of a felony?

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* 10. Emergency Contact:

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* 11. How did you learn about this volunteer opportunity?

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* 12. Any other information we need to know?

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* 13. Release of Information:
After reading the information release statement, please type in your initials in the blank box.

I hereby certify to the best of my knowledge, the information I have provided is accurate. I am providing my contact information to be kept confidential in the volunteer database. This database will be used in the event of a disaster and/or to promote community preparedness. I acknowledge that health department staff may need to contact me periodically to maintain the accuracy of this information, inform me of training opportunities, or to test their communication plan’s effectiveness. I authorize health department staff to contact me or my emergency contact listed above, utilizing any or all of these methods, and I agree to release all of the above-named entities from liability arising from any volunteer service I may perform. I also authorize any of the entities mentioned above to conduct a background check on me with the information I have provided.

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* 14. Signature (initials) of Parent/Guardian if under 19

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* 15. I am interested in receiving emergency notices and notices of FREE educational opportunities by email.

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* 16. I am interested in receiving a radon test kit for my home.

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* 17. I am interested in receiving a FREE colon cancer test kit (Age 50 and older).

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* 18. I am interested in receiving a wellness / heart health screening.

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* 19. I am interested in information on helping kids choose to be alcohol and drug free

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* 20. I am interested in information about attending a Tai Chi class.

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* 21. I am interested in information about being a Community Health Worker

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* 22. I am interested in receiving information on the Colon Cancer Coalition.

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* 23. I am interested in becoming a Tai Chi fitness class instructor.

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* 24. Do you have unused, expired or unwanted prescription or over-the-counter medication(s) that you would like to dispose of?

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* 25. I am interested in receiving information about the Every Woman Matters program.

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* 26. I am interested in receiving information about weight loss / healthy lifestyle classes.

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* 27. Have you or an immediate family member served in the military?

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