Assistance Request Intake Scout Form



Date:_________Volunteer #: ______Joplin May 2011 Tornado Recovery Task ForceVolunteer Intake Form Name: _________________________________________ Birthdate: ___/___/______Address: ______________________________________________________________City: ______________________________________ State: _____ ZIP: __________Phone number: ______________________ E-mail: ___________________________Occupation: ________________________ Employer: _________________________Availability: ______________________________________________________Emergency contact: _____________________________________________________Relationship: ____________________ Phone number: ________________________Are you currently affiliated with a disaster relief agency? ___Yes ___NoIf so, what agency? _____________________________________________________Name: _________________________________________ Birthdate: ___/___/______Address: ______________________________________________________________City: ______________________________________ State: _____ ZIP: __________Phone number: ______________________ E-mail: ___________________________Occupation: ________________________ Employer: _________________________Availability: ______________________________________________________Emergency contact: _____________________________________________________Relationship: ____________________ Phone number: ________________________Are you currently affiliated with a disaster relief agency? ___Yes ___NoIf so, what agency? _____________________________________________________PLEASE CHECK ALL SKILLS THAT APPLY:MEDICAL:____ Doctor – indicate speciality: ___________________________________ Nurse – indicate speciality: ___________________________________ Emergency medical certification____ Mental health counseling____ Veterinarian____ Veterinary technician____ First Aid (current card? ___Yes ___No)____ CPR (current card? ___Yes ___No)____ Survival training and techniqueCOMMUNICATIONS:____ CB operator____ Ham radio operator____ Telephone receptionist____ Public relations____ Web page designLANGUAGES:____ French____ German____ Italian____ Spanish____ Other: ________________________________EQUIPMENT:____ Backhoe ____ Chainsaw____ Generator____ Dozer____ Other: _____________________________SERVICE:____ Food____ Elderly____ Disabled____ Child care____ Spiritual counseling____ Social work____ Search and rescue____ Auto repair/towing____ Traffic control____ Crime watch____ Animal rescue____ Animal care____ Emergency planning____ Law enforcement____ Emergency management____ FirefightingOFFICE SUPPORT:____ Clerical – filing, copying, etc.____ Data entry____ Software: _____________________________TRANSPORTATION:____ Car____ Station wagon/minivan____ ATV____ Off road vehicle/4-wheel drive____ Boat – capacity: ____________________ Commercial driver – class and license #: _____________________________________ Camper/RV – capacity and type: _____________________________ _____________________________STRUCTUAL:____ Damage assessment____ Metal construction____ Wood construction____ Block construction____ Plumbing____ Electrical____ Roofing____ Structual engineeringLABOR:____ Loading and shipping____ Sorting/packing____ Clean-up____ Debris clearance____ Operate equipment____ Experience in supervising and managing othersOTHER SKILLS: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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