Fill In the Form Below

In the event of an emergency it is very important that the Health Department is able to contact voluteers with the necessary training to set-up and run its POD's. In an effort to keep this information as current as possible; the Shasta County Health Department has developed the form below. When you have completed filling in the form please click the Send button to send your information to the Health Department's Disaster Healthcare Volunteer Coordinator.

First Name: Last Name:

Home Address: City: Zipcode:

Work Address: City: Zipcode:

Home Phone: Work Phone: Cell Phone:

Numeric Pager: Alpha-Numeric Pager:

Primary E-Mail: Secondary E-mail:

If you have any certifications which may aid in Emergency Response please list them in the field below:


Do you currently volunteer for any other agencies in an emergency capacity? (Example: Red Cross)


Have you previously volunteered during a disaster? If so When and Where? (Example: Hurricane Katrina, Florida)


Do you have experience coordinating large events? Describe:


Languages (Hold the Ctrl button down to select multiple languages)

Have Specialized Experience? (Hold the Ctrl button down to select multiple values)

I'm Interested In Volunteering For Other Public Health Preparedness Activities!

Please Contact Me About Site Specific Registration!

If you use a web based e-mail system like hotmail or g-mail this form may not automatically send. To download a Word version of the form which can be printed or sent as an attachment: Click here for the Shasta County form.