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Emergency Volunteer Registration Form

2. Authorization for Release of Information
   By checking the box below, I acknowledge and agree that I am freely volunteering my services to the City of Burnsville to assist in and during the current emergency or disaster. I acknowledge and agree to act under the direction and control of the City’s Emergency Manager, or his/her designee, and if I fail to act in accordance with the direction and control of the City’s Emergency Manager, or his/her designee, I will be dismissed as a volunteer and I shall leave the area immediately. Finally, I acknowledge and agree to indemnify and hold the City harmless for any injury, harm or damage caused by or to me, except as otherwise protected under Minn. Stat. §12.22. I further acknowledge that I understand the type of work that is required and I self certify that I am able to complete these tasks.

   By checking the box below, I acknowledge and agree that I am freely volunteering my services to the City of Burnsville to assist in and during the current emergency or disaster. I acknowledge and agree to act under the direction and control of the City’s Emergency Manager, or his/her designee, and if I fail to act in accordance with the direction and control of the City’s Emergency Manager, or his/her designee, I will be dismissed as a volunteer and I shall leave the area immediately. Finally, I acknowledge and agree to indemnify and hold the City harmless for any injury, harm or damage caused by or to me, except as otherwise protected under Minn. Stat. §12.22. I further acknowledge that I understand the type of work that is required and I self certify that I am able to complete these tasks.

4. Click Yes to Agree*

   1. YES

6. Contact Information

8. First Name (Full)*

9. Last Name (Full)*

10. Middle Name (Full)*

12. Date of Birth*

14. Address1*

16. Address2

18. City*

19. State*

20. Zip*

22. Primary Phone:*

23. Cell Phone:

24. Work Phone:

26. Abilities:

    1. Able to Lift or Pull up to 40 pounds?

    1. Request Light Duty?

    Check all that apply.

27. Special Skills:

29. Emergency Contact Information

31. First Name:*

32. Last Name*

33. Middle Name:

35. Relationship:*

37. Address:*

39. City*

40. State*

41. Zip*

43. Primary Phone:*

44. Cell Phone:

45. Work Phone

47. By checking "Yes," I agree to allow the Burnsville Police Department to run a Minnesota Criminal History Check on me for the purposes of determining my suitability for this program. I hereby acknowledge that I have completed the above information fully and accurately.*

    1. YES

49. Volunteers Under 18: I give permission for my child to participate.

    1. YES

51. Parent's First and Last Name

53. 
    

Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field