American Red Cross

American Red Cross

Volunteer Information Record

DATE

Home Contact Information                 (LAST)                                                      ( FIRST)                                                                           ( MIDDLE)                            MALE FEMALE
       NAME

                                           (STREET)
       HOME ADDRESS         HOME PHONE
         (CITY)                                                       (STATE)                                                    (ZIP)
                     CELL PHONE

        E-MAIL ADDRESS             FAX

Work Contact Information                                             (COMPANY NAME)
        WORK ADDRESS         WORK PHONE
          (STREET)                                                                (CITY)                                                              (STATE)                        (ZIP)
          WORK FAX


        Florida Resident:    Full Time        Part Time        What Months Are You Here?

Interests Here are some critical areas in which we always need volunteers, which ones are you most interested in? (Please check all that apply)

    Disaster Action Team ( the team which responds to local disasters, such as fires)
    Disaster Preparedness and helping during a disaster
    Community Disaster Education
    Armed Forces Emergency Services        Case Work            Projects
    Office Support
    Health & Safety        Become an Instructor            Projects
    Fund Raising             Events             Planning
    I have no idea but am willing to learn anything.

Special Skills Do you have special skills, experiences and / or licenses that may be useful as a Red Cross Volunteer? Please describe below.

Have you been a Red Cross Volunteer elsewhere? YES        NO
If yes which chapter        City        State
Are you a licensed driver    YES       NO        License Number         State
Is it necessary to limit your physical activity?   YES        NO
Are you a licensed nurse?    YES           NO
Are you a licensed Mental Health Worker?       YES           NO
Do you speak any language other than English?    YES           NO     Languages you speak

Your Emergency Contact Information Individual to be notified in case of emergency:

Name Relationship

Address Phone Cell
Address 2

Additional Information Check One:    Age: 25+    19-24    18 & Under
Birth date
Race: White     Hispanic     Black     Asian/Pacific Islander        Native American/Alaskan
NOTE: This information is OPTIONAL and to be used for statistical reasons ONLY.

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