Waterbury Department of Public Health

Volunteer Data Form
If you have questions about volunteering,
contact John Bayusik at (203) 346-3906

Name:
Mailing Address:
Town: State: Zip Code:

Please list any special skills or knowledge (i.e. computer skills, foreign language, etc.)

Phone (Day):
Cell Phone:
Phone (Evening):
Fax:
Email Address: *REQUIRED

Which of the above is the best way to reach you in an emergency?
Phone (Day)
Phone (Evening)
Email
Cell Phone
Fax
Please note, it is not necessary to have a medical background to volunteer.

Do you have a professional health / medical background?

If YES, please complete the following information:
M.D.
R.N.
L.P.N.
E.M.T.
P.A.
A.P.R.N.
Paramedic
Other
Professional License Number: Date of Expiration

Please indicate your area of specialty (if applicable)

Name of Practice (if applicable)
Address of Practice
Town: State: Zip Code:

Are you currently licensed by the State of CT to administer vaccinations?

All information submitted will be kept confidential.

If you have any questions about volunteering please contact John Bayusik, Emergency Preparedness Coordinator.

Volunteering will require a minimal commitment (less than 4 hours per year) unless an actual emergency event occurs.

If you have friends, family, or co-workers interested in volunteering, please have them visit our website.