How to Enlist
Sign on in advance to help in times of disaster. Tell us how to get in touch with you:
Date of Birth:
Address:
City:
State:
Zip:
Phone Day:
Phone Evening:
Fax:
Cell:
Email:
Place of Employment:
Skills/Profession/Areas of Interest
(Check appropriate categories and any special skills for category) Note: If license/certfication is required, you must provide it upon request.
Administration/Supervision
Animal Care
Animal Rescue
CDL Bus Driver Trucker
Child Care
Communications Ham Radio/CB Radio Cellular Phones Other
Computer Skills Computer Operation Computer Repair/Installation Data Entry Other
Construction/Repair Home Repair Welding Other
Counseling School Counselor Clergy Licensed Mental Health Practitioner Psychiatrist Psychological First-Aid Other
Damage Assessment
Debris Removal/Clean-Up
Driving
EMT/Fire & Rescue
Farmer
Guiding Traffic
Food Service Food Preparation Food Management Other
General Office Skills
Heavy Equipment Operator Fork Lift Other
Languages Spanish speak read understand Sign Other Law Enforcement
Mechanical Ability
Medical/Veterinary Dentist LabTech/MT Physician NP PA Technician Paramedic LPN RN Veterinarian X-Ray Other
Missing Person Search
Mortuary Service
Security Experience
Shelter Services
Seniors Disabled Other
Teacher
Waste Disposal
Other
I prefer to be:
Inactive (prepared for service only in an emergency or disaster) Active (leader, United Way, Chamber of Commerce, community health initiatives)
In what Counties would you be available to volunteer?
Scotts Bluff
Banner
Box Butte
Cheyenne
Dawes
Deuel
Garden
Kimball
Morrill
Sheridan
Sioux
Any Nebraska County
Are you currently in good health?:
Yes No
I would be interested in volunteering for these current services:
Delivering meals on wheels - 11:50-12:00 - Mon thru Fri on days at your convenience.
Shopping for seniors - 8:00 a.m.-10:30 a.m. - Tuesday mornings at your convenience.
Youth Services - Examples: mentoring, buckboard therapeutic riding, Scout leaders.
By Submitting this Form, I hereby make application to become a disaster response volunteer in the area. I also hereby give permission for this information to be shared exclusively between the United Way of Western Nebraska, Scotts Bluff County Health Department, Panhandle Public Health District, Scotts Bluff County Emergency Management, and the North Platte Valley Chapter of the American Red Cross.
