Response Team Sign Up

Please use the form below to sign up to for the Winston-Salem Hurricane Florence Humanitarian Response Team to Eastern North Carolina trip from Oct 21 (5pm) - Oct 27, 2018.

Name *
Date of Birth *
Date of Birth
Phone *
Emergency Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
I am
please check any that apply
Next Steps
Please submit this form below, read and sign below liability form and email the form and a copy of your ID to