COVID-19 Volunteer Intake Thank you for your dedication to our community! Please complete the following information and Tri-County Health Network will contact you with information on how you can help. Please note that fields marked with an asterisk (*) are required. General Information Name* Phone/Cell (Format: 123-456-7890)* Email* Best way to contact you* —emailphonetext Town* Date of Birth (If the calendar selector gives you a hard time, you can enter your birth date, by hand, using the mm/dd/yyyy format.)* What languages do you speak? (Select all that apply) EnglishSpanishOther Do you want to offer financial support?* YesNo If yes, please visit the Telluride Foundation Response Fund webpage after completing this form. Do you want to offer clinical skills?* YesNo If yes, please answer the following questions below: Licensure/Credentials? Active License in CO?* YesNo Active License or Retired?—ActiveRetired Languages spoken? Trained in venipuncture?*YesNo Specialty (if any)? Patient population willing to serve? (Select all that apply) —PediactricsAll agesGeriatricsOther If “Other,” please define: Other clinical skills (list)? Do you want to offer resources (i.e. physical items)?* YesNo If yes, please answer the following questions below: What are you offering? (Select all that apply) —HousingFoodVehicleStorageSuppliesOther Please explain or list in more detail: Do you want to offer services?* YesNo If yes, please answer the following questions below: What are you offering? (Select all that apply) —Food PrepTransportationErrandsPet CareTranslation ServicesEmotional SupportOther Please explain or list in more detail: Skills and Abilities Are you capable of lifting 20 pounds?*YesNo Are you in a risk category (immunocompromised, chronic condition including asthma, hypertension, diabetes, etc.)?*YesNo Are you willing to leave your home? (following most recent San Miguel County orders and recommendations, such as being 6ft. away from others and in groups no larger than 10 people)?* YesNo Knowledge of Microsoft Word (scale 1 – 5) —12345 Knowledge of Microsoft Excel (scale 1 – 5) —12345 Previous office/project management experience?*YesNo If yes, please explain: Other special skills or, areas of expertise you’d like to offer? Emergency Contact Emergency Contact Name* Emergency Contact Relationship* Emergency Contact Phone/Cell (Format: 123-456-7890)* San Miguel County Volunteer Notification and Waiver of Liability I, (the “volunteer”) as a volunteer for the county, do hereby and forever release and discharge San Miguel County (“county”) government and respective board members, officers, employees, agents and volunteers from any and all claims, actions, expenses, liabilities, or damages of any nature whatsoever, including costs and attorney’s fees, arising out of any personal injury or any loss or damage to property in any way resulting from or otherwise relating to my participation as a county volunteer. I fully understand and agree to provide my services to the county as a volunteer in a volunteer capacity. County employees may volunteer to serve in a volunteer program so long as their activities do not directly relate to their county job. I fully understand that the county will not provide or pay for medical treatment for injuries that occur within the scope and course of my volunteer activities. I fully understand that as a volunteer, I do not work for the county as an employee, therefore, I am not entitled to workers’ compensation benefits and the county cannot provide lost wages or permanent disability benefits for the volunteer’s regular employment. I fully understand and agree that if I use my personal vehicle while conducting volunteer county business, my personal automobile insurance is my responsibility and primary to any other insurance that may exist. I fully understand and agree that if I use any of my personal property while conducting volunteer county business, the county will not provide insurance coverage or be financially responsible should damage or loss occur. I fully understand that as a county volunteer, I am covered by the county’s liability insurance to the same degree and conditions as a county employee. By signing this form, the undersigned is aware of, understands the nature of the county volunteer program and the participation requirements and conditions and agrees to the above. Electronic Signature Agreement: The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. Volunteer Signature (or parent/guardian if less than 18)* (Use your mouse or trackpad to sign.) Printed Name* Relationship to Volunteer (if less than 18) *SelfParent/Guardian Today’s Date* If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again. If you continue to get an error message, please call (704.236.4425) M-F 8 -5 for assistance.