Form Center

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.
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:


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

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field