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Emergency Volunteer Registration Form
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This form has been modified since it was saved. Please review all fields before submitting.
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.
Click Yes to Agree
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YES
Contact Information
First Name (Full)
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Last Name (Full)
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Middle Name (Full)
*
Date of Birth
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Address1
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Address2
City
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State
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Zip
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Primary Phone:
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Cell Phone:
Work Phone:
Abilities:
Able to Lift or Pull up to 40 pounds?
Request Light Duty?
Check all that apply.
Special Skills:
Emergency Contact Information
First Name:
*
Last Name
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Middle Name:
Relationship:
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Address:
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City
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State
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Zip
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Primary Phone:
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Cell Phone:
Work Phone
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.
*
YES
Volunteers Under 18: I give permission for my child to participate.
YES
Parent's First and Last Name
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