Winnebago County Health Department

How To Volunteer

 

First Name: *
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Desired Username: *
Desired Password: *

Note: Please enter a username and password (8 digits or more using any alpha/numeric combination). Your username and password will be used throughout the Emergencies/Disasters portion of the Web site. If you forget your username and password please email us at sguedet@wchd.org.

Address:
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E-mail: *
Current Employer:

Are you a medically licensed professional?



IF NOT LICENSED: Fill In General Information
Check all boxes that describe your specific skillset.





IF LICENSED: Fill in Medically Licensed Information
Are you a physician? 
Areas of Specialty:  

Are you board certified?

Are you a nurse?




Do you have prescriptive authority?

Check all of your fields of specialty that apply.

Is current Illinois licensure or certification required to practice in your profession and field of specialty?
Illinois License #:
Certification #:


Step 3 of 3
Are you CPR certified?

Are you First Aid certified?

Are you part of any other emergency/disaster alert system?

If yes, which other systems?

Do you have a current Illinois Driver's License?

Do you have foreign language fluency?
What language(s)?:

Do you have any teaching experience?
Explain:

Do you have children or family members that would need care in the event that you are activated?
Emergency contact  #:

I prefer to be:

Availability  (if active):

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