Delaware County, IN / Action Center / Emergency Management Volunteer Application /

Last Name*

First Name*

Middle Name*

Date of Birth*

MonthDay Year,

Home Address (house, street, city, state, zip)*

Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Email*

Do you have a valid driver's license?*

YES

NO

Previous volunteer experience or other relevant experience

Education Information

Highest completed level of education*

High School

Some College

College Degree

Graduate Degree

If applicable, list the college you are currently attending*

If applicable, please denote what academic year you are in currently

I need volunteer hours for school credit

Please Do Not Complete The Following Field

Credit Hours needed

If applicable, list the Colleges/universities you ahve graduated from

Employement Information

Your Employer*

Your Position*

Volunteer Interests

Why do you want to volunteer in Emergency management*

I would like to volunteer with (check all that apply)*

Would you prefer to volunteer*

Please note your most likely times of availability (all volunteer opportunities will/may vary):

Volunteer Privacy Information and Release Authorization

Please read the following carefully Application information I certify that all information in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration for volunteer service and may result in my dismissal, if discovered, at a later date.

I agree with the above statement*

YES

References & Background Investigations

I understand that Delaware County Emergency Management requires information from me to evaluate my qualifications for volunteer service. I authorize and release personal references, employers (past and present), and, if necessary, other applicable entities to answer questions in regards to volunteer work, employment, ability, character, medical and emotional background and, if applicable, driving history. I also understand, in consideration of my application, a background investigation will be conducted. I understand this investigation may include, but is not limited to, a criminal background check in the files of any Federal, state or local justice agency, driving history, performance of medical examinations, drug screening or reference verification. I authorize Delaware County Emergency management and associated entities (collectively Delaware County) to conduct the background investigation and release Delaware County from responsibility for this investigation. I understand the requested information is for the sole purpose of gathering accurate information for volunteer services at Delaware County Emergency Management and within the community we serve.

I have read the application and upon approval I will provide my signature for the back ground investigation*

YES

enter today's date (MONTH/DAY/YEAR)*

Delaware County, Indiana

Discover Delaware County - an east central Indiana community of opportunity

Emergency Management Volunteer Application