Volunteer Application

MIAMI COUNTY HEALTH DEPT, 25 Court Street Room 203, Peru, IN 46970

Personal Information

Name: ___________________________________________________________________________
Address: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Phone - Home: __________ Work: __________ Cell: ___________ E-Mail:_________________
Employment: ______________________________________________________________________
Emergency Contact Information: ______________________________________________________
Describe any restrictions on your activities (physical, medical) ______________________________
_________________________________________________________________________________
Date of last Tetanus Immunization: ____________________________________________________
Are you currently charged with or have you ever been convicted of a felony? YES___ NO___
If YES, please explain: ______________________________________________________________
Your Availability: ___________________________________________________________________
Do you have personal transportation? YES___ NO___

Skills and Qualifications

Fluency in Language(s) other than English? _____________________________________________
Licenses/ Professional Certifications: __________________________________________________

_________________________________________________________________________________

Professional Background: ___________________________________________________________
Education Background: _____________________________________________________________
Computer Skills: __________________________________________________________________
Prior or current volunteer experience: _________________________________________________

_________________________________________________________________________________
Other Skills (please check all that apply):
__ Administrative/ Secretarial            __ Accounting/ Finance/ Bookkeeping/ Human Resources
__ Civil Servant (Police, Firefighter)   __ Child Care
__ Customer Service                        __ Food Service
__ Health Services ( Physician, Dentist, Pharmacist, Nurse, EMT, CAN, QMA, Mental Health)
__ Counselor/ Social Worker             __ Management
__ Technical                                     __ Transportation (professional truck/ bus driver)
__ Trade:_________________________________________________________________________
__ Other: _________________________________________________________________________

The information you provide will be secured within the MIAMI COUNTY HEALTH DEPT and will not be shared with any other government or non- government agencies without your expressed approval. This information will be utilized to provide volunteer staffing for a Health Department response to a county emergency or disaster.

Signature: ____________________________________Date: ____________________________

Please return your completed volunteer form to:
MIAMI COUNTY HEALTH DEPT, Public Health Coordinator, 25 Court St., Room 203, Peru, IN 46970