Lutheran Disaster Response Network of Northeastern Pennsylvania

Disaster Response Form For Individual Volunteers

Please fill out the form as completely as possible to have your information added to the Lutheran Disaster Response Network- Northeastern Pennsylvania Data Base (TEAM). The areas marked in red are required in order for the form to process.

For further information about volunteering or filling out this form, call Ruth or Dianne at 610.770.9205 or email them at ruth@lutherancongregationalservices.org or dianne@lutherancongregationalservices.org.

Name:
Address:
City:
State:
ZIP:
County:
Telephone:
Fax:
Email:
If you are a member of a community of faith, please indicate denomination:
If Lutheran, are you a member of Thrivent?
ARE YOU OFFERING ASSISTANCE AS AN INDIVIDUAL OR AS A PART OF A CONGREGATION OR COMMUNITY GROUP/ORGANIZATION?
Individual	Congregation	Community Group/Organization
If part of a group, a congregation or a group/organization, what is the name of the congregation/group/organization?
Address:
City:
County:
State:
Zip:
If this is a religious group, what is the denomination?
Please describe the work you are willing to do:
Do you have any of these skills that you are willing to offer?
Case Manager Carpenter Chaplain Civil Engineer Clerical Worker Contractor Cook Counselors Critical Incident Stress Debriefing (CISD) Worker Deaf Interpreter Dentist Doctor Electrician EMT Financial Resource Advisor Maintenance Worker Nurse Parish Nurse Pastor Plumber Public Official Public Relations/Media Support Worker Social Worker Stephen Minister Telecommunication worker Work Groups
Please describe your SKILLS AND ANY TRAINING for this work:
Are you able to volunteer any of the EQUIPMENT listed below?
Bus Cell Phone Child Care Cleaning Supplies Clothing Drinking Water Food Furniture Generator Hand Tools Internet Accessible Computer Meals Meals at your location Meals at Disaster Site Medical Equipment/Supplies Power Equipment Power Tools Two-way Radios Vans Work Vehicle Other:
Please list any special certifications or trainings (e.g. EMT, MD, RN, licensed electrician, licensed plumber, licensed clinical social worker, trained Stephen Minister, etc.)
Please list any previous experience you have in Emergency Services and Disaster Response:
Are you willing to travel to affected areas outside of Northeastern PA?
Are you interested in joining our current work rebuilding flooded properties in Northampton County?
When are you available?
Other Information?
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