California Veterinary Medical Association
Disaster Response Volunteer Sign Up Form
County:
Name:
Home Address:
City/Zip Code:
Business Address:
City/Zip Code:
Home Phone:
Business Phone:
Fax Phone:
Cellular Phone:
Pager:
Email:
Ham Radio:
VETERINARY AFFILIATION:
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Practice Owner
R.V.T. (licensed)
Veterinary Assistant
Lab Animal Veterinarian
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Government
Clinical Pathology
Educational Institution
Industry
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Clinical associate/relief veterinarian
Other (specify)
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What is your area of clinical interest? (check all that apply)
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1.
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Species:
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small animal
food animal
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equine
avian/exotic
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lab animal
other (specify)
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|
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2.
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Emphasis:
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general practice
internal medicine
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surgery
ophthalmology
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3.
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Are you board certified?
No
Yes (specify)
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Do you have formal or volunteer training in animal rehabilitation or rescue?
No Yes (specify)
Do you have formal or volunteer training in canine search and rescue programs ?
No Yes (specify)
Do you have formal or volunteer training in other search and rescue programs?
No Yes (specify)
Do you have previous experience in disasters? No Yes
If yes, please list briefly:
Please check skills you possess that might be valuable in emergency situations:
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Media training
Ham Radio
Cellular Phone
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Photography equipment/skills
Emergency communications
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American Red Cross Training (specify)
Other (specify)
Do you own a practice?
Yes No
Would you be willing to make it available for animal care during a disaster?
Yes No
THANK YOU FOR COMPLETING THIS SURVEY & SIGN UP SHEET. YOUR NAME WILL BE ADDED TO THE VOLUNTEER DATABASE FOR CVMA AND DISTRIBUTED TO LOCAL AGENCIES AND YOUR LOCAL VETERINARY
COORDINATOR.
Please return this form to:
CVMA Disaster Response Coordinator,
1400 River Park Drive, Suite 100, Sacramento, CA 95815, or fax to (916) 646-9156,
or email to [email protected].