Volunteer with American Red Cross

| Des Moines Smoke Alarm Project

October 12th, 2013
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Registration Information

Required fields are marked with an asterisk (*)
First Name *
Last Name *
Email Address *
Phone (available on day of event) *
Are you 18 or over? *
Are you willing to serve as a Task Force Leader (Installer)? *
Would you be willing to bring a cordless drill for use during this event? *
Would you be willing to bring a 3 foot step ladder for this event? *
Are you required to register with the State of Iowa for any reason *
Is anyone volunteering with you?
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Information Release
I give to the American Red Cross, its designees, agents and assigns, unlimited permission to use, publish and
republish in any form or media, information about me and reproductions of my likeness (photographic or otherwise) and my voice, with or without identification of me by name.

Consent of parent or legal guardian if above individual is a minor.
I consent and agree, individually and as parent or legal guardian of the minor named above, to the foregoing
terms and provisions.

Name of person photographed, recorded or interviewed Age (if minor)
(Please print)
Street address, city, state and ZIP code
E-mail / Phone number
Signature Date
F5244 (Rev. June 2006)
Signature Date
Printed Name / Relationship
Producer, writer,or photographer
Event / Location Image number
Caption Info / Description of photo
Autorización para el uso y
distribución de información
Autorizo a la Cruz Roja Americana y a sus designatarios,
representantes y agentes a usar y publicar sin restricciones y
cuantas veces sea necesario, bajo cualquier forma o medio,
información referente a mi persona incluyendo reproducciones
de mi retrato (fotográficas o de otro tipo) o de mi voz, con o
sin mi nombre.
Consentimiento del padre/madre o representante legal si la persona
anteriormente mencionada es menor de edad. Consiento y apruebo,
individualmente como padre/madre o representante legal del
menor de edad arriba citado, a los términos y estipulaciones de la
presente autorización.
Nombre de la persona fotografiada, entrevistada o cuya Edad (si es menor de edad)
voz ha sido grabada (Por favor use letra de imprenta.)
Dirección (calle, ciudad, estado y código postal)
Correo electrónico/Número de teléfono
Firma Fecha
F5244 (Rev. June 2006)
Firma Fecha
Nombre en letra de imprenta / Vínculo
Productor, escritor o fotógrafo
Acontecimiento/Lugar Imagen núm.
Leyenda o descripción para la fotografia
Enter your name here to serve as a digital signature: