P.O. Box 2550, Fort Pierce, FL 34954
Telephone: 1 (866) 558-2287 (ACTS)
Website: http://www.actshelp.org

   

To volunteer for ACTS Disaster Response, please fill out the following form:

(NOTE: Fields denoted with a * are required)

Disaster Volunteer Registration Form

*Name

 

M.I.


Day Phone
Email
 
 
Relationship
Occupation
Employer

Business
Address

City
State
Zip
 
When
Available?
For how long?
Weekends?
Yes No
During the week?
Yes No
What special skills and/or vocational or disaster training have you had?
Describe any previous experience you have had?
Are you currently affliated with any other disaster relief agency?
Yes, Agency Name  
No
Do you have a camper or mobile home?
Yes
No
 
What general area(s) of work would you like to be involved in?

Debris Removal

Distribution of Supplies

Mass Feeding
Medical Care
Office/Clerical
Structural Repair
Transportation
Warehousing
What area(s) of leadership (organize and direct a team) would you like to be involved in?
Community Needs Director
Mass Distribution Director
Mass Feeding Director
Medical Director
Security & Signage Director
Spiritual Director
Volunteer Coordinator
 
 
 
 


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Disaster Volunteer Registration Form

What general area(s) of work would you like to be involved in?
 
MEDICAL
 
STRUCTURAL
Doctor Specialty:
Damage assessment
 
Nurse Specialty:
 
Metal construction
 
Emergency Medical Cert.
 
Wood construction
 
Mental health counseling
 
Block construction Cert #
 
Veterinarian
 
Plunbing Cert.#
 
Veterinarian technician
 
Electrical Cert.#
 
 
Roofing Cert.#
 
 
 
COMMUNICATIONS
 
TRANSPORTATION
 
CB or ham operator
 
Car
 
Hotline Operator
 
Station wagon/mini van
 
Own a cell phone #
 
Maxi-van, capacity:
 
Own a skyphone #
 
ATV
 
Public relations
 
Own off-road vehicle/4wd
 
Web page design
 
Own truck, description:
 
Public Speaker
 
Own boat, capacity: type:
 
 
Commercial Driver Class:
State: License#
 
LANGUAGES (other than English)
 
 
French
 
Camper.RV, Capacity: Type:
 
German
 
 
Italian
 
OFFICE SUPPORT
 
Spanish
 
Clerical - filing, copying
 
Ukranian
 
Computer Hardware: Type:
 
 
Data entry software:
 
 
Phone receptionist
 
 
 
 
LABOR
 
SERVICE
 
Loading/shipping
 
Food
 
Sorting/packing
 
Elderly/Disabled assistance
 
Clean-up
 
Child care
 
Operate Equipment Types:
 
Spiritual counseling
 
Exoerience supervising others
 
Social work
 
 
Search and rescue
 
EQUIPMENT
 
Auto repair/towing
 
Heavy Equipment Type:
 
Traffic control
 
Chainsaw
 
Crime watch
 
Forklift
 
Animal rescue
 
Generator
 
Animal care
 
Other:
 
Runner
 
 

 

Additional Comments/Notes:

 


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Disaster Volunteer Registration Form

Release of Liability


I, for myself and my heirs, executors, administrators and assigns, hereby release, indemnify, and hold harmless A.C.T.S., local governments, State of Florida, the organizers, sponsors and supervisors of all disaster preparedness, response and recovery activities from all liability for any and all risk of damage or bodily injury or death that may occur to me (including any injury caused by negligence), in connection with any volunteer disaster effort in which I participate. I likewise hold harmless from liability any person transporting me to or from any disaster relief activity. In addition, disaster relief officials have permission to utilize any photographs or videos taken of me for publicity or training purposes. I will abide by all safety instructions and information provided to me during disaster relief efforts.

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 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 sign this release as my own free act.

 

By checking this box, I hereby acknowledge:
    (1) that I am at least 18 years of age, and
    (2) I agree to the terms stated in the preceding Release of Liability, and
    (3) I give permission to ACTS to perform a background check on me.

 
We treat your registration information as private and confidential.

   
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