About You

What is your name?  

Where do you live?

       Address:   

 

    Town/City:  

 

                      State:      Zip/Postal Code:   

 

What is your D.O.B.?              Month January February March April May June July August September October November December                    DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Year:  (4 digits)

List your Shield Number (if applicable):   (This will be your ID/reference number)

What size shirt do you wear?                    Please specify your size Small Medium Large Extra Large 2XX Large Other

Are you a Male or Female?         Please specify your gender Male Female

Tell us how to get in touch with you:

E-mail
Tel		xxx-xxx-xxxx
Mobile		xxx-xxx-xxxx
FAX		xxx-xxx-xxxx

Best time to contact you

Are you in Law Enforcement or other valid emergency service?

            Yes No

If you answered YES, what branch are you in?  

IF you checked NO above, what is the name of the person you know going?

     Name of Person going:   

Have you ever been in any of the ARMED FORCES?

            Yes No

IF you checked YES above, please list which one?

Who do we contact in case of an Emergency?

       Address:   

 

    Town/City:   

 

                      State:        Zip/Postal Code: 

 

          Phone:      

 Contact Name/Relationship:    

Your Work

Where do you work?  

         Address:   

 

      Town/City:   

 

                        State:     Zip/Postal Code:          

What are you good at?

                Select all that apply.  If you can't pick any, that's still ok.  We'll still find a place for you.  We will need "Gophers", people to move supplies around,  and people to hold items while they are being placed.

If you picked any of the following trades, please list your level of experience:

Are there any other trades you're good at? 

What will you need to bring?  We ask that everyone try to bring the basics.  Please check that you have the following:

           - Hammer                            - Screwdriver (Both Flat and Phillips)

              -  Wire cutters                    - Tool Belt

              -  Utility Knife                     - Screw Gun (If you have one)      

           - Pliers (linesman)             - Measuring Tape

              -  gloves                             -  Sheetrock Utility Saw

How's you health?

Do you have any health conditions that might impair your trip or volunteer work ?

            Yes No

Have you ever had to take sick time for these health conditions that would affect your trip or volunteer work?

            Yes No

If you answered "Yes" to either question above, please explain in the box below:

Do you have any allergies?  Please include medications you are allergic to:

            Yes No

If you answered "Yes" to the question above, please explain in the box below:     

Mold is a big issues in areas affected by water, such as New Orleans.  Have you ever had a reaction to mold or do you have any concerns about being around mold?

            Yes No

If you answered "Yes" to the question above, please explain in the box below:

Do you understand that in places, such as New Orleans, temperatures can reach up to 100° and higher with high humidity?

            Yes No

Do you have any respiratory problems?

            Yes No

If you answered "Yes" to the question above, please explain in the box below:

Do you have any cardiac problems?

            Yes No

If you answered "Yes" to the question above, please explain in the box below:

Do you have any type of back problems?

            Yes No

If you answered "Yes" to the question above, please explain in the box below:

Do you feel you are in good physical condition?

            Yes No

Do you have any type of medical training?

            Yes No

Please explain your level of training and any certifications you hold (if applicable).

When would you like to go?

Please to see a calendar to help you look up dates:

In the boxes below are trips that are either confirmed or in the making.  If you would like One of these confirmed/suggested dates, please chose one:

            Choose a date in the works To be announced

If you would like to try to have us consider a trip on a date OTHER than above OR if you have at least 8 people already and would like to form a trip (It can be an "only" trip.  Ex - If you'd like just a Lieutenant only, Sergeant only, a precinct only, firefighter only...you get the idea).  You can also begin a trip and we can add to it.

                  Month January February March April May June July August September October November December        DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31         Year 2007 2008 2009 2010 2011 2012

Are you interested in helping out for more than one week?

            Yes No

Travel Info:

          In case you are selected and flying, we need to know what airports service your area:

Airlines info:

          As an added benefit, we try to apply air miles to each person.  If you have any airline mile accounts you would like applied, please let us know.   If we can add them, we will.  This way you get credit for the trip.  The most common airlines we use are: American, United, and Delta.  List any you have and if you'd like, register for these.  We will do our best.

After you click "Submit comments."  you will be taken to a confirmation page and given a chance to sign up for our forum.

We also have a forum so you may:

   - Discuss your trip with others going the same time you are.

   - Discuss job issues

   - Meet people

   - Learn

   - Discuss things from the job you may have seen or experienced that are "weighing you down"

  After you click submit, please go to our forum section and sign up there also.  You will have to enter some information that is the same, but we do this so the forum can remain anonymous.