American Red Cross Form 1492a - Local Disaster Volunteer Staff Registration
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1
2LOCAL DISASTER VOLUNTEER
STAFF REGISTRATION
DISASTER RELIEF OPERATION #__________ DISASTER RELIEF OPERATION NAME________________________________________________
___________________________________________________________________________________________________________________________________________
LAST NAME
FIRST NAME
MI
PREFERRED NAME
DSHR ID NUMBER
___________________________________________________________________________________________________________________________________________
HOME ADDRESS
CITY
STATE
ZIP
(
)_______________________________________
(
)_______________________________________
HOME PHONE
ALTERNATE PHONE
PERSON TO NOTIFY IN EMERGENCY:
______________________________________________________________________________________________(
)___________________________________
NAME
RELATIONSHIP
PHONE
______________________________________________________________________________________________(
)____________________________________
ADDRESS
CITY
STATE
ZIP
ALTERNATE PHONE
Ë
AFFILIATION: (If no affiliation, check box
)
ARE YOU A DSHR SYSTEM MEMBER? [ ] YES [ ] NO
RED CROSS________________________________________________________________________________________________________ _________________
UNIT NAME
CITY
STATE
UNIT CODE
OTHER GROUP/AGENCY/ORG/COMPANY: _____________________________________________________________________________________________
NAME
_____________________________________________________________________________________________ (
)___________________________________
ADDRESS
CITY
STATE
ZIP
PHONE
_____________________________________________________ (
)_______________________________ (
)___________________________________
CONTACT PERSON
PHONE
ALTERNATE PHONE
FOR LDV FUNCTION USE ONLY
PERSONNEL CATEGORY:
____VOL ____VOL/T&M ____VOL/MMI
[
] CHAPTER [
] GROUP [
] SPONTANEOUS [
] YOUTH/YOUNG ADULT
ASSIGNMENT INFO:
FIRST
SECOND
THIRD
DATE:
__________________________________________________________________________________________________________
FUNCTION:
__________________________________________________________________________________________________________
POSITION:
__________________________________________________________________________________________________________
LOCATION:
__________________________________________________________________________________________________________
DAYS/HOURS AVAILABLE: (Please mark the appropriate day/time)
MON
TUE
WED
THUR
FRI
SAT
SUN
AM
PM
EVE
WHAT WOULD YOU LIKE TO DO?____________________________________________________________________________________________________________
PRIOR WORK WITH AMERICAN RED CROSS? [ ] YES [ ] NO IF YES, WHEN AND WHAT_________________________________________________
___________________________________________________________________________________________________________________________________________
DRIVER'S LICENSE #___________________________________ STATE___________
________/ ________/ ________
________/ ________/ ________
FIRST DAY OF WORK
AVAILABLE THROUGH
DID YOU RECEIVE DAMAGE FROM THE DISASTER? [ ] YES [ ] NO
DO YOU HAVE PERSONAL TRANSPORTATION? [ ] YES [ ] NO
ARE YOU: UNDER 18 YEARS OLD [ ] 18-24 [ ] 25 OR OLDER [ ]
LANGUAGES? (other than English)_____________________________
SPECIAL SKILLS: (Include any licenses held other than Driver's License)______________________________________________________________________________
WORDPROCESSING: [ ] YES [ ] NO _____wpm COMPUTER SOFTWARE FAMILIARITY: __________________________________________________
I VERIFY THAT I HAVE NOT BEEN CONVICTED OF A FELONY OR, WITHIN THE LAST 24 MONTHS, BEEN CONVICTED OF A MISDEMEANOR THAT
RESULTED IN IMPRISONMENT. IF THIS STATEMENT IS INCOMPLETE OR UNTRUE, I UNDERSTAND MY ASSIGNMENT WILL BE TERMINATED. I
HAVE READ THE FUNDAMENTAL PRINCIPLES OF THE RED CROSS MOVEMENT AND STANDARDS OF CONDUCT FOR DISASTER RELIEF
WORKERS ON THE BACK OF THIS FORM AND AGREE TO ABIDE BY THEM DURING MY ASSIGNMENT WITH THE AMERICAN RED CROSS. IF THIS
STATEMENT IS INCOMPLETE OR UNTRUE, I UNDERSTAND MY ASSIGNMENT WILL BE TERMINATED.
DISASTER WORKER'S SIGNATURE________________________________________________________________________ DATE___________________________
American Red Cross Form 1492A (Rev. 8-00)
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