County Animal Care Volunteer ERPA

County Animal Care Volunteer

Emergency Response Personnel Application- 20

Name___________________________________________________________________
Last First MI

Home Address____________________________________________________________

Number and Street City Zip

Area or cross streets _______________________________________________________

Home Phone ( ) ____________________ Fax ( ) ____________________

Pager ( ) ____________________ Cellular ( ) _____________________

Employer________________________________________________________________

Work Address____________________________________________________________

Number and Street City Zip

Work Phone ( ) ____________________ Fax ( ) ____________________
May we call you at work? ‘ Yes ‘ No

Medical Insurance Carrier ___________________ Policy Number ___________________

Physician ______________________________ Phone ( ) ____________________

Any Medical Conditions? ‘ No ‘ Yes: ____________________________________

Driver’s License Number ___________________ Expiration Date _____/______/_______

Vehicle License Plate Number _______________ Description ____________________

Trailer License Plate Number ________________ Description ____________________

Do you have Standardized Emergency Management System (SEMS) training? ‘ Yes

‘ No

Additional Disaster Training or Experience (i.e., DART) __________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Signature _____________________________________________ Date _____________

Approved By __________________________________________ Date _____________

^{20-Adapted from the Indiana State Annex for Veterinary
Emergencies Committee and Help Us Get Them to Safety! by the Nevada

County Unit of the CVMA}