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EMERGENCY INCIDENT SUPPORT (EIS)
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13395 Voyager Pkwy
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Suite 130-PMB226
VOLUNTEER APPLICATION
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Colorado Springs, CO 80921
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 SERVING THOSE WHO SERVE
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 Name: Last, First, Middle Initial
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 Address: Street, City, State, Zip
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 Email AddressCell Phone Number (Include Area Code)Type of Phone (Android, iPhone)
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 Alternate Email Address Home Phone Number (Include Area Code)Work Phone Number (Include Area Code)
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Needed for ID Badge
___ Copy of Drivers License attached to application
___ Photo attached to application (digital, color, white background)
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T-Shirt Size ___ Small ___ Medium ___ Large ___ XL ___ XXL
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PERSON TO CONTACT IN CASE OF EMERGENCY
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 Name: Last, First, Middle InitialRelationship
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 Address: Street, City, State, Zip
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Cell Phone Number (Include Area Code) Home Phone Number (Include Area Code)Work Phone Number (Include Area Code)
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REFERENCES: List Two Personal References - Please do not Include relatives
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 1. Name: Last, First, Middle InitialRelationship
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 Address: Street, City, State, Zip
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Cell Phone Number (Include Area Code) Home Phone Number (Include Area Code)Work Phone Number (Include Area Code)
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 2. Name: Last, First, Middle InitialRelationship
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 Address: Street, City, State, Zip
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Cell Phone Number (Include Area Code) Home Phone Number (Include Area Code)Work Phone Number (Include Area Code)
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Volunteer Experience
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 Previous or Present Volunteer Experience (CERT, EPSO, etc.):
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 Briefly Explain Why You Chose to Volunteer for EIS:
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Indicate areas of interest for volunteering:
___ Training (Training Coordinator needed)
___ Safety
___ Vehicle Maintenance
___ Driver
___ Response Coordinator
___ Website/IT
___ Publicity
___ Event Planning
___ Food Preparation
___ Supplies and Warehouse
___ Grant writing
___ Other ______________________________________________
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Availability for Disaster Response
Please indicate your availability to respond to an event:
___ Daytime
___ During the night
___ Weekends
Times not available: _________________________________________________

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Incident Command System (ICS)
Persons authorized to be on an incident scene operate under ICS protocols (training.fema.gov).
EIS strongly recommends that applicant complete ICS 100 and 700.
If you have completed ICS 100 and/or 700, please attach certificate.
___ Yes ___ No
EIS offers to provide another member as a mentor.
Indicate if you would like a mentor. _____________
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INTERESTS
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Certificates or Special Courses (i.e., CPR, CERT, Food Handler):
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Foreign Language (Speak, Read, Write) Please Specify:
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 Area(s) of Expertise (Food Prep, cooking, HAM Radio, etc.):
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 Hobbies, Interests and Skills:
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AFFIRMATION
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I certify that all information in this EIS Application is true and correct to the best of my knowledge, and I agree that falsification and / or omission of information considered by EIS to be material may result in my disqualification from consideration as volunteer or my dismissal from EIS.
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I hereby release EIS and all duly authorized agents, both individually and collectively, from any and all liability for damage of whatever kind, which may at any time result to me, my heirs, or my assigns because of compliance with this authorization and request to release information, or any attempt to comply with it.
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I acknowledge if I am a volunteer with EIS I am obliged to follow all federal rules, regulations and protocols.
By signing this application I hereby grant my permission to EIS to review, inspect and otherwise verify my references and qualifications.
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I understand information provided on this application is to determine my qualifications and fitness. EIS realizes the personally identifiable Information will be held in the strictest confidence and release will only be made in accordance with state and federal regulations.
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As a volunteer, I will receive from EIS certain information relating to the business and operations of EIS and the events to which EIS responds; public disclosure is strictly prohibited. Such information is acknowledged to be confidential, proprietary and protected by EIS, state and/or federal law(s). Volunteers will use every reasonable effort to keep confidential information and will not disclose to third parties or use for personal gain. Such disclosures or uses shall include, but not be limited to: disclosure to the media and publication in books, magazines, periodicals, or any other form of information distributed to the public, whether the medium be printed, film, video, electronic media, or otherwise. This nondisclosure does not apply to criminal justice agencies.
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Signature
Date
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