Volunteer LDV Application

Online Volunteer Application

Local Disaster Volunteer

Jackson Area Chapter, Jackson, TN

In order to have your application processed, you must thoroughly answered all questions. Applications filled out incompletely will not be considered. You may post your resume at the end of this form; however, it will not substitute for completing any portion of this application. All information will be treated confidentially.

Personal Information:

Name: Last First MI

Address

City State Zip

County       Home Phone

Mobile Phone             Fax

E-mail Address

Work/Company Name

Work Phone Job Title

Work Address

City State Zip

Years/Experience

Emergency Contact Relationship

Phone     Mobile Phone

Reference 1 Name Employer     Friend (Not a Relative)

Phone City State

Reference 2 Name Employer     Friend (Not a Relative)

Phone City State

Driver's License No. State Type

Driving Restrictions

Have You Ever Taken a Drivers Education or Defensive Driving Course? Yes     No    Date

Do You have Any Current Driving Infractions? Yes     No      How Many? 1 2 3

If Yes, Explain

Has Your License Ever Been Revoked or Suspended? Yes    No

If Yes, Explain

Do You Have Personal Transportation? Yes    No            Do You Have Vehicle Insurance? Yes   No

If Yes, are You Willing To Use Your Vehicle for Red Cross Disaster Relief Activities? Yes    No

Have You Been Convicted for a Misdemeanor or Felony Charge within the Last 24 Month? Yes    No

If Yes, Explain

Have You Ever Worked as a Paid Red Cross Employee? Yes    No     As a Red Cross Volunteer? Yes    No

If Yes, List Activities You Worked in

Previous Chapter's Name Number of Years Worked

Address/City/ST/Zip Phone

Education and Training:

Are You a High School Student? Yes    No        Name of School:

High School Grade Completed: 8 9 10 11 12 GED      Participate in: Jr. ROTC   School Clubs

Are You a College or Vocational Student? Yes   No   Name of School:

College Years Completed: 1 2 3 Bachelors Masters Doctorate    Major:

Vocational/Military Training Years Completed: 1 2 3 4     Specialty:

   Military Service: Army Air Force Navy MarinesReserves National Guard    Status:Active Retired

Special Skill/Hobbies/Interest:

Health Services: Doctor/Type: RN LPN CNAEMT Other:

ScoutingHam RadioCivil Air PatrolLifeguardSwimming InstructorVolunteer FiremanPoliceman

Typing Skills:GoodAverageMinimal   WPM: Computer Skills:GoodAverageMinimalWebmaster

Speak/Read Foreign Language (Specify): Speak OnlyRead Only Fluent

Volunteer Service Availability:

Days Available: Monday Tuesday   Wednesday Thursday Friday Saturday Sunday

Times Available: MorningAfternoonEvening                Number of Hours Per Week You Can Volunteer:

Volunteer Service Opportunities (Check 3 Activities Which Interest You):

Receptionist Assistant (Work reception desk, telephones, take messages, typing, copying, and general administration)

Health and Safety Assistant (Assist Heath & Safety office with cleaning and maintenance of manikins and housekeeping)

Public Affairs Assistant (Assist with public relations, press releases, advertising and general administration)

Fund Raising Assistant (Assist with disaster relief fund raising, accounting and general administration)

Data Entry Assistant (Assist various departments with computer data input of personnel and training records)

CPR and First-Aid Volunteer Instructor (Teach Adult CPR, Infant & Child CPR and First Aid Classes)

Disaster Instructor (Teach Disaster Relief Classes & Community Disaster Preparedness Presentations)

Disaster Assessment (Assessing type, amount and damage of disaster area; finding victims, completing DA forms)

Staffing-Human Resources (Scheduling volunteer assignments, tracking volunteer personnel and training records)

Mass Care (Assisting victims of disaster; working in disaster shelters; fixed and mobile feeding; distribution of supplies)

ERV Driver (Drive Mobile Feeding Vehicles in disaster areas; distributing food & supplies to victims & emergency workers)

Client Casework-Family Services (Interviewing clients; issuing vouchers for emergency needs for food, clothes & medicine)

Disaster Health Services (RN's and Doctors Helping disaster victims with health issues and basic first aid in shelters)

Mental Health Services (Licensed Counselors Helping disaster victims with Mental health issues and counseling in shelters)

Records and Reports (Reviewing casework forms, filing paperwork, auditing and financial calculations)

Logistics (Managing material & supplies in disaster warehouses; inventory, requisition, delivery, maintenance & storage)

IT/Computers (Computer operations and maintenance; telephone operations; networking and general IT management)

Partner Services (Government Liaison EOC, Community Relations Liaison, Labor Liaison, Voluntary Agency Liaison)

DSHR Volunteer (Disaster Trained Volunteers who travel to National Disaster Relief Operations for 3-week assignments)

Statistical EEOC Information (Check all that apply):

Gender: Male   Female                                        Age:                              Are You a U.S. Citizen? Yes No

Race: Black White Hispanic Asian Pacific Islander American Indian Alaskan Native   Other

Disabled: Yes No             Is it necessary to limit your physical activity in any way? Yes No

If yes, what is your limitation?

Employed Unemployed Retired Homemaker                           College Student: Full-Time Part-Time

Veteran U.S. Military Disable Veteran     Branch of Service:

If you are Licensed Professional, complete the following:   Profession:

License No:    State:     Expiration Date:

Background Check Consent:

To maintain the trust of the American people and provide them with the best quality service, all Red Cross employees and volunteers must be background checked. All information will be treated confidentially:

(Type in Full Name) (please check all that apply):

Yes I do, No I do not hereby give the American Red Cross, permission to inquire into my educational background, references, driving record, employment history and police records. I give permission to the holder of any such records to release the same to the American Red Cross, Jackson Area Chapter, 1981 Hollywood Drive, Suite 100, Jackson, TN 38305. If, you checked I do not, you are disqualified from working as a Red Cross employee or volunteer, proceed no further.

Yes, Upon my acceptance as a Red Cross Volunteer, I agree to go online to www.mybackgroundcheck.com/ArcVts/ and complete my required Red Cross Background Check.

Yes, I hereby hold the American Red Cross, Jackson Area Chapter, Jackson, TN harmless of any liability whether civil or criminal that may arise as a result of the release of this information about me. I further hold harmless any individual, agency, business, or corporation that provides information or documents to the Jackson Area Chapter that is responsive to a request for release of information.

Yes, I understand that the Jackson Area Chapter, will use this information as part of its verification of my application to serve as a volunteer in the American Red Cross, Jackson Area Chapter, 1981 Hollywood Drive, Suite 100, Jackson, TN 38305.

E-mail Address: Date of Birth:

Social Security No:     Mother's Maiden Name:

Drivers License No: State Issue Date Expiration Date

Post Resume (Copy and Paste):

Comments or Questions:

   Please Double Check Your Entries Before Submitting The Form

Personal Information:
*Name: Last*	First MI
*Address*
*City*	*State* *Zip*
*County*	*Home Phone*
*Mobile Phone*	*Fax*
*E-mail Address*
Work/Company Name
*Work Phone*	Job Title
Work *Address*
*City*	*State* *Zip*
Years/Experience
Emergency Contact	Relationship
Phone	*Mobile Phone*
Reference 1 Name	Employer Friend (Not a Relative)
Phone	*City* *State*
Reference 2 Name	Employer Friend (Not a Relative)
Phone	*City* *State*
Driver's License No.	*State* *Type*
*Driving Restrictions*
Have You Ever Taken a Drivers Education or Defensive Driving Course? Yes *No Date*
Do You have Any Current Driving Infractions? Yes *No How Many? 1* 2 3
*If Yes, Explain*
Has Your License Ever Been Revoked or Suspended? Yes No
*If Yes, Explain*
*Do You Have Personal Transportation?* Yes No *Do You Have Vehicle Insurance?* Yes No
If Yes, are You Willing To Use Your Vehicle for Red Cross Disaster Relief Activities? Yes No
*Have You Been Convicted for a Misdemeanor or Felony Charge within the Last 24 Month?* Yes No
*If Yes, Explain*
Have You Ever Worked as a Paid Red Cross Employee? Yes No *As a* Red Cross *Volunteer?* Yes No
*If Yes, List Activities You Worked in*
Previous Chapter's Name Number of Years Worked
Address/City/ST/Zip *Phone*
Education and Training:
*Are You a High School Student?* Yes No Name of *School:*
High School Grade Completed: 8 9 10 11 12 *GED Participate in:* Jr. ROTC School Clubs
*Are You a College or Vocational Student?* Yes No Name of *School:*
College Years Completed: 1 2 3 *Bachelors* *Masters* *Doctorate Major:*
Vocational/Military Training Years Completed: 1 2 3 4 Specialty:
Military Service: *Army* Air Force Navy *Marines*Reserves *National Guard Status:Active* Retired**
Special Skill/Hobbies/Interest:
Health Services: *Doctor/Type:* RN *LPN* *CNAEMT* Other:**
*ScoutingHam RadioCivil Air PatrolLifeguardSwimming InstructorVolunteer FiremanPoliceman*
*Typing Skills:GoodAverageMinimal WPM:* Computer Skills:GoodAverageMinimalWebmaster**
Speak/Read Foreign Language (Specify): *Speak OnlyRead Only* Fluent**
Volunteer Service Availability:
Days Available: *Monday* *Tuesday* *Wednesday* Thursday *Friday* *Saturday* *Sunday*
Times Available: *MorningAfternoonEvening Number of Hours Per Week You Can Volunteer:*
Volunteer Service Opportunities (Check 3 Activities Which Interest You):
Receptionist Assistant (Work reception desk, telephones, take messages, typing, copying, and general administration)
Health and Safety Assistant (Assist Heath & Safety office with cleaning and maintenance of manikins and housekeeping)
Public Affairs Assistant (Assist with public relations, press releases, advertising and general administration)
Fund Raising Assistant (Assist with disaster relief fund raising, accounting and general administration)
Data Entry Assistant (Assist various departments with computer data input of personnel and training records)
CPR and First-Aid Volunteer Instructor (Teach Adult CPR, Infant & Child CPR and First Aid Classes)
Disaster Instructor (Teach Disaster Relief Classes & Community Disaster Preparedness Presentations)
Disaster Assessment (Assessing type, amount and damage of disaster area; finding victims, completing DA forms)
Staffing-Human Resources (Scheduling volunteer assignments, tracking volunteer personnel and training records)
Mass Care (Assisting victims of disaster; working in disaster shelters; fixed and mobile feeding; distribution of supplies)
ERV Driver (Drive Mobile Feeding Vehicles in disaster areas; distributing food & supplies to victims & emergency workers)
Client Casework-Family Services (Interviewing clients; issuing vouchers for emergency needs for food, clothes & medicine)
Disaster Health Services (RN's and Doctors Helping disaster victims with health issues and basic first aid in shelters)
Mental Health Services (Licensed Counselors Helping disaster victims with Mental health issues and counseling in shelters)
Records and Reports (Reviewing casework forms, filing paperwork, auditing and financial calculations)
Logistics (Managing material & supplies in disaster warehouses; inventory, requisition, delivery, maintenance & storage)
IT/Computers (Computer operations and maintenance; telephone operations; networking and general IT management)
Partner Services (Government Liaison EOC, Community Relations Liaison, Labor Liaison, Voluntary Agency Liaison)
DSHR Volunteer (Disaster Trained Volunteers who travel to National Disaster Relief Operations for 3-week assignments)
Statistical EEOC Information (Check all that apply):
Gender: Male Female Age: Are You a U.S. Citizen? Yes No
Race: Black White Hispanic Asian Pacific Islander American Indian Alaskan Native Other
Disabled: Yes No Is it necessary to limit your physical activity in any way? Yes No
If yes, what is your limitation?
Employed Unemployed Retired Homemaker College Student: Full-Time Part-Time
Veteran U.S. Military Disable Veteran Branch of Service:
If you are Licensed Professional, complete the following: Profession:
License No: State: Expiration Date:
Background Check Consent:
To maintain the trust of the American people and provide them with the best quality service, all Red Cross employees and volunteers must be background checked. All information will be treated confidentially:
(Type in Full Name) (please check all that apply):
Yes I do, No I do not hereby give the American Red Cross, permission to inquire into my educational background, references, driving record, employment history and police records. I give permission to the holder of any such records to release the same to the American Red Cross, Jackson Area Chapter, 1981 Hollywood Drive, Suite 100, Jackson, TN 38305. If, you checked I do not, you are disqualified from working as a Red Cross employee or volunteer, proceed no further.
Yes, Upon my acceptance as a Red Cross Volunteer, I agree to go online to www.mybackgroundcheck.com/ArcVts/ and complete my required Red Cross Background Check.
Yes, I hereby hold the American Red Cross, Jackson Area Chapter, Jackson, TN harmless of any liability whether civil or criminal that may arise as a result of the release of this information about me. I further hold harmless any individual, agency, business, or corporation that provides information or documents to the Jackson Area Chapter that is responsive to a request for release of information.
Yes, I understand that the Jackson Area Chapter, will use this information as part of its verification of my application to serve as a volunteer in the American Red Cross, Jackson Area Chapter, 1981 Hollywood Drive, Suite 100, Jackson, TN 38305.
E-mail Address: Date of Birth:
Social Security No: Mother's Maiden Name:
Drivers License No: State Issue Date Expiration Date
Post Resume (Copy and Paste):

Comments or Questions:

Please Double Check Your Entries Before Submitting The Form