Personal Information:

First Name:                           Middle Initial                               Last Name:                      
Mailing Address:                      
              City:                         State:                           Zip Code:                          County you reside in:                      

Email Address:                       

In the event of a disaster, we will need to get in touch with you at all times of the day.  Would you please supply us with the following telephone numbers:
Daytime:    Is that number:  Work Home Other
Evening:      Is that number: Work Home Other
Cell/Pager
   
Date of Birth (for statistics only):                        Month January February March April May June July August September October November December                          Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  
(You must be 18 years of age or older to register)

Distance you are willing to travel to help:  Miles 0-15 15-30 30-45 45-60 60-75 75-90 90+

Which county or counties are you interested in volunteering for?
Washington         Ozaukee                 Sheboygan
Waukesha           Milwaukee             Fond du Lac
Racine                Kenosha                Dodge
Jefferson             Walworth

Select all of the following programs that interest you:

Neighborhood Watch Programs (citizen involvement in discouraging and preventing residential crime. 
  The program uses citizen involvement to secure their own home and personal property and to report
 any suspicious activity.  It is a willingness to get to know your neighbor)      
Fire Department: Volunteering through your local fire department  
Community Emergency Response Team (CERT)
Medical Reserve Corps                         
Volunteers in Police Service (VIPS)  (Called Communications Patrol/Auxiliary Police in Kewaskum and
  West Bend.  Help police with traffic direction, security, child finger printing, adverse weather spotting,
  locating missing persons, and helping with Neighborhood Watch Programs)
Current emergency-related volunteering
Emergency activation only
**Background screening will be conducted.

There are many ways we can use your skills and/or equipment.  Please check all the boxes that you would like to offer.

Using Your Training and/or Profession:  The following categories are skills that you probably use at your job and
could be applied in the event of a disaster:
Agricultural Livestock Professional
Animal Care Certifications (Vet, Vet Tech, Humane Society/Animal Shelter)
Building/Construction Professionals (engineers, architects, contractors)
Children Support Services Professional (DSS, Social Workers, educators Children's Therapists, Childcare)
Educator
Financial Professionals (banking, accounting, bookkeeping, adviser)
Homemaker
Hospitality Professional (restaurant workers, hotel management/staff)
Management Professional (administrators, volunteer managers, managerial)
Medical Certifications (R.N., L.P.N., Physician, C.N.A., CPR Certified, Anesthesiologist, etc)
Office/Clerical (Computer skills, Telephone Skills, Filling, Data Entry)
Professionals Offering Emotional and Spiritual Support
Skilled Trades Certifications (carpentry, electrician, plumbing, heating/cooling, etc)
Technology Professionals (Telephone, computer networking, communication, systems)
Transportation (CDL License, Bus driver, semi driver, etc)

Skill Not Listed Above:  Please Describe Your Skill

Using Your Skills and Experience:
Agricultural/Livestock (herding cattle, assessing wellbeing, animal management)
Care for People (childcare, phone tree, for seniors)
Domestic (cleaning, cooking/feeding large groups, food preparation, laundry, etc)
First Aid/CPR Certified
Home Handyman/Handywoman (knowledge of electricity, plumbing, carpentry, remodeling)
Manual Help (clearing branches, lifting cinderblocks, moving debris, loading/unloading supplies)
Pet Care (comforting house pets, transporting, foster care for pets -- cats, dogs, guinea pigs)
Runner (run errands/supplies)
Security, perimeter control, loss prevention
Transport People/Supplies
Other Skill Not Listed 

Equipment/Supply/Storage Available:
Animal Boarding  (for cattle, horses, livestock, { kennel facilities, barns})
Boat(s)
Equipment/Tools (chainsaws, power tools, generators, front-end loaders, dump trucks, lighting)         Describe equipment
Storage Space:Describe space available and what area of the county the space is in.
Supplies
Vehicle (cars, trucks, horse/cattle trailers, 4-wheelers, tractors, vans, gators, etc.)


            Thank you for offering up your time, services, and equipment!