Town of Bethel Connecticut - Health Department - Community Emergency Response Volunteer Application

Bethel Health Department

Region 6, MDA - (Mass Dispensing Area)

COMMUNITY EMERGENCY RESPONSE VOLUNTEERS (CERV)
Learn Our Town's Plan And Where You Might Fit In

Helping hands are needed in all areas [i.e. traffic control, floaters (escorts), phone personnel, food service, forms (handing, approving, assist in completing) clinic supply management, data processing, safety, etc]. Medical volunteers are needed also and people to assist them.

Community Emergency Response Volunteer Application

Please fill in the form on the computer and submit. Information will go to Bethel Health Department to be entered into the Local Health Alert Network database. This database is used to send out Health Alerts, Health Advisories and/or Health Updates of public health incidents and/or situations occurring in the community.

* = required field

* Name:

* Home Address:

* City:

* State:

*Zip

* Home Phone:

Home Fax #:

Home Email:

Work Name

Work Address:

City:

State:

Zip

Work Phone:

Home Fax #:

Work Email:

Occupation/Skills:

Cell phone #:

Text Messaging: Yes No

Check any area you would be able to help us:
Customer Service	Food Service
Scheduling	Public Speaking
Planning	Secretarial
Management	Foreign Language
Finance	Technical Background
Communication	Computers
Supply Management	Audio Visual
Special Needs/Elderly Care	Data Input
Security	Other