Volunteer Application – Pennsylvania Emergency Response Center Inc.

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Name *

First

Middle

Last

Gender *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phones

Please include at least 1 phone number

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Phone Type *

Phone Number *

Email *

Marital Status *

Do you have Children? *

Yes
No

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Child's First Name

Child's Age

Drivers License & Vehicle Information

The State of PA requires that all motorist have a valid drivers’s license and proof of insurance. As many of our official activities require driving your personal vehicle or may require you to drive a team owned vehicles, it is necessary for us to ask for this information. Failure to supply this information will not affect your application to volunteer

Do you have a Valid Drivers License *

Yes
No

Employment Information

It is the policy of Pennsylvania Emergency Response Center NOT TO RELEASE work locations or phone numbers without prior permission of the member involved. However, it is of benefit to the team to be aware of where our members are employed, to avoid cases of conflict of interest or accidentally jeopardizing a members’s job. Failure to supply this information will not affect your application for membership.

Employer

Position / Duties

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Emergency Contact(s)

Name *

First

Last

Phone *

Relationship *

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Physicians Name

Physicians Phone

Other Organizations

Due to the multitude of other agencies or organizations that Pennsylvania Emergency Response Center works closely with, it is important for us to know what other organizations, clubs, etc. that you my currently belong to. This information will enable us to determine the amount of time that you may be able to contribute as a volunteer of Pennsylvania Emergency Response Center in time of emergency. For example, belonging to a Volunteer Fire Department may cause a conflict if Pennsylvania Emergency Response Center is called out at the same time to help with the fire or other disaster. Your duties with the VFD take priority over those in Pennsylvania Emergency Response Center, thus making you unavailable at that time. No Volunteer is expected to be 100% available. There will always be time when your family, church, employment or other obligations may take priority over Pennsylvania Emergency Response Center Team meeting or activities

Repeater

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Name of Organization

Your Position

Purpose of Organization

Personal References

Please include at least 3

Personal References

Reference Name *

Reference Email, Phone Number, or Address *

Relationship *

Skills

Likert Scale *

	Not Familiar	Little Familiar	Somewhat Familiar	Very Familiar
Amateur Radio	Not FamiliarAmateur Radio Not Familiar	Little FamiliarAmateur Radio Little Familiar	Somewhat FamiliarAmateur Radio Somewhat Familiar	Very FamiliarAmateur Radio Very Familiar
Marketing / Events	Not FamiliarMarketing / Events Not Familiar	Little FamiliarMarketing / Events Little Familiar	Somewhat FamiliarMarketing / Events Somewhat Familiar	Very FamiliarMarketing / Events Very Familiar
IT Networks	Not FamiliarIT Networks Not Familiar	Little FamiliarIT Networks Little Familiar	Somewhat FamiliarIT Networks Somewhat Familiar	Very FamiliarIT Networks Very Familiar
IT System Administration	Not FamiliarIT System Administration Not Familiar	Little FamiliarIT System Administration Little Familiar	Somewhat FamiliarIT System Administration Somewhat Familiar	Very FamiliarIT System Administration Very Familiar
Research	Not FamiliarResearch Not Familiar	Little FamiliarResearch Little Familiar	Somewhat FamiliarResearch Somewhat Familiar	Very FamiliarResearch Very Familiar
Drones	Not FamiliarDrones Not Familiar	Little FamiliarDrones Little Familiar	Somewhat FamiliarDrones Somewhat Familiar	Very FamiliarDrones Very Familiar
Sonar	Not FamiliarSonar Not Familiar	Little FamiliarSonar Little Familiar	Somewhat FamiliarSonar Somewhat Familiar	Very FamiliarSonar Very Familiar
Rescue Dogs	Not FamiliarRescue Dogs Not Familiar	Little FamiliarRescue Dogs Little Familiar	Somewhat FamiliarRescue Dogs Somewhat Familiar	Very FamiliarRescue Dogs Very Familiar
Search & Rescue	Not FamiliarSearch & Rescue Not Familiar	Little FamiliarSearch & Rescue Little Familiar	Somewhat FamiliarSearch & Rescue Somewhat Familiar	Very FamiliarSearch & Rescue Very Familiar

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Are you a licensed Amateur Radio Operator *

Yes
No

Other Information

Please list all breeds of dogs, or other skills you have. Our volunteers come from a wide variety of backgrounds and experiences. It is extremely helpful to the Board of Directors to be aware of any special skills, training, or hobbies that may be of use to the team. This includes such things as medical training, disaster training, special drivers licenses, scuba and others. This list is endless. Failure to supply this information will not affect your application to become a volunteer.

T-Shirt Size *

All Sizes are Adult Unisex

List of impairments, limitations, phobias, etc.

We ask that you provide this information so that we can work with you in your position as a volunteer. Someone who is claustrophobic, we would not ask to go into a small cave or tunnel. This information is to help us help you

Do you have a criminal record? *

Yes
No

Due to the nature of our services, the possibility of involvement with children, we require this information. We cannot accept volunteers that have been convicted of a felony. Additionally, any conviction of any crime related to kidnapping, abduction, assault, indecency with a child/cadaver, rape, molestation or registered as a child offender will disqualify this application immediately. All other criminal charges will be looked at on a case by case basis. But, failure to supply this information will result in a rejection of this application.

What Team or Teams are you Interested in working with?

Acceptance

The information contained on this Volunteer Application will remain confidential and will not be released outside of the Board of Directors without your permission, other than for use in official Team rosters or registration and/or insurance purposes.

By entering your name below, you are giving the Pennsylvania Emergency Response Center Board of Directors explicit permission to contact the references that you have provided and to conduct a background check with local law enforcement agencies (at PennERC expense). No medical exams are required. The results of any such investigation may become a part of this application.

In the event of acceptance, you agree to follow the rules and regulations outlined in the Team’s bylaws (as may be amended by the Board of Directors) and will conduct yourself in such a manner as to not reflect unfavorably upon the PennERC Team.
You will be on probation for 60 days following your acceptance of this application.

You certify that all answers given on this application are true to the best of your knowledge and that this is not an application for employment. Acceptance is dependent upon a vote of the Board of Directors.

Signature *