Medical Licensed Personnel Volunteer Form Volunteer positions supporting the Whatcom Unified Command COVID-19 response involve potential risks to personal health and safety. These potential risks range from personal injury through physical hazards such as slips, trips and falls, lifting heavy objects, driving, or operating equipment, to potential transmission of the Coronavirus that causes COVID-19. To minimize potential risks, volunteers must be capable of physical activity and follow required safety plans. Volunteers must be free of COVID-19 symptoms for a minimum of 72 hours, and it must be at least one week since the beginning of symptoms. Volunteers must disclose any history of COVID-19 symptoms.”*Yes, I understand.Name* First Last Home PhoneCell Phone*Email* AvailabilityPlease select the day(s) you would be available to work. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Please provide any additional information about your availability.Skills and TrainingAre you currently affiliated with a disaster relief organization?* Yes No If "Yes" list the organizationAre you currently registered as an emergency worker?* Yes No If "Yes" please provide your Emergency Worker Card NumberCheck all currently held* Certified Medical Assistant (CMA) Certified Nursing Assistant (CNA) Doctor/MD Licensed Practicing Nurse (LPN) Nurse Practitioner (ARNP) Physician's Assistant (PA) Registered Nurse (RN) Social Worker (MSW) (LSW) Paramedic (PM), Emergency Medical Technician (EMT), Emergency Medical Responder (EMR), Wilderness First Responder (WFR), Wilderness First Aid (WFA), Outdoor Emergency Care (OEC) Behavorial Health Specialist Are you currently licensed in Washington State?* Yes No You will be asked to present your license or certification at a later date.Have you completed ICS Training?* Yes No If "Yes" Please list the courses you have completed. Separate each with a comma.List special equipment/vehicles/resources you can offerIs there any additional information you would like to share with us?Health Query* I am over 60 years of age I have chronic lung disease or moderate to severe asthma I have serious heart disease I am immunocompromised including cancer treatment I am pregnant None of the above apply to me Volunteer Agreement: I hereby certify that the facts set forth in this volunteer application are true and correct to the best of my knowledge. I agree that if the information given in my application or any other materials, or during any interview, is found to be false in any way, it shall be considered sufficient cause for denial of volunteer status. I understand that the Unified Command is not obligated to appoint me to a volunteer position and that nothing contained in the volunteer registration form is intended to create a contract between Unified Command and me. I agree to comply with all policies, rules, regulations and procedures of Unified Command, which I understand may change at any time; and I understand that my volunteer status can be terminated with or without cause or notice, at any time, at the option of either me or Unified Command.*Yes, I agree.Enter an alternate Email address:Terms and Conditions: I Agree. Enter an alternate Email address:Terms and Conditions: I Agree. Enter an alternate Email address:Terms and Conditions: I Agree. Enter an alternate Email address:Terms and Conditions: I Agree. Enter an alternate Email address:Terms and Conditions: I Agree.