LSS of South Dakota Disaster Response Services Volunteer Intake Form

First Name (Required)

Last Name (Required)

Country

Address Line 1 *

Address Line 2 *

City *

State/Province *

Postal Code *

Birthdate (Required)

Home Phone (Required)

Work Phone (Required)

Cell Phone (Required)

E-mail (Required)

Arrival Date (Required)

Departure Date (Required)

Need housing?

Will pay for lodging?

Local lodging at (Required)

Need meals?

Need RV hookup?

Do you need transportation to work site?

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Previous disaster experience?

If so, where?

Are you a member of Thrivent Financial for Lutherans?

Member of fraternal benefit organization?

Health Issues (Required)

Tetanus shot needed?

Date of last tetanus shot? (Required)

Emergency Contact Name (Required)

Emergency Contact Relationship (Required)

Phone (Required)

Cell Phone (Required)