Personal and Medical Information for Volunteers Name * First Name Last Name Home address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Main phone number * (###) ### #### Secondary phone number (###) ### #### Church name * Church address * Address 1 Address 2 City State/Province Zip/Postal Code Country Is your church part of the BCNE? * Yes No Employer and job title * Date of birth * MM DD YYYY Height * Weight * Hair color * Eye color * Gender * Male Female Languages other than English * Emergency contact #1 * First Name Last Name Relationship with emergency contact #1 * Phone for emergency contact #1 * (###) ### #### Address for emergency contact #1 * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency contact #2 * First Name Last Name Relationship with emergency contact #2 * Phone for emergency contact #2 * (###) ### #### Address for emergency contact #2 * Address 1 Address 2 City State/Province Zip/Postal Code Country Physician's name * First Name Last Name Physician's phone * (###) ### #### Health insurance company * Health insurance group/policy number * Health insurance phone * (###) ### #### Medications, allergies, and other pertinent medical information * Additional training * Please list other applicable skills training, certification or experience, such as EMT, CPR, nursing, electrical/trades, Red Cross, etc. How long could you serve in one call up? * Less than 1 week 1 week More than 1 week How quickly could you respond to a call up? * 1 day 3 days 1 week Longer than 1 week Do you plan to respond to a Disaster Relief New England call up in the next 3 years? * Yes, if possible No Thank you!
