SERVPA:

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Account Information

Creating an account is the first step in the SERVPA registration process. You will use your account username and password each time you log into SERVPA.

Username:

The username must be at least six (6) characters long and cannot contain spaces. Acceptable characters include alphanumeric (A-Z, 0-9) and the symbols @, ., -, and _. Usernames are not case sensitive.

Password:

Confirm Password:

Secret Question:

Secret Answer:

Terms of Service and Privacy Policy

Required field Terms of Service:

By checking this box, I indicate that I agree to the Terms of Service and have read and understand the Privacy Policy for this site. My submission of this form will constitute my consent to the collection and use of this information and the transfer of this information across the Internet to processing and storage facilities supporting this system. I also agree to receive required administrative and legal notices such as this electronically.

Required field Information Pledge:

By checking this box, I pledge to provide only correct information when completing this registration process. I also give consent to SERVPA and their designated agents to collect, use, verify, and maintain any information that is collected through the use of this site.

Required field Certification:

I certify that all of the statements made by me are true, complete, and correct, to the best of my knowledge and belief, and are made in good faith. I understand that this certification is subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities. I am aware that all statements made by me on this document are subject to investigation.

Required field Authorization:

I do hereby authorize the Commonwealth of Pennsylvania to research and copy records including, but not limited to, educational, professional, judicial; armed services; Federal, state and local law enforcement; motor vehicle and driving safety; and any other documents, data, and information that may be necessary and practical in order to conduct an investigation; and to contact past and present employers as well as professional references for information. I also authorize the release of the above mentioned records to the Commonwealth of Pennsylvania. My consent, however, is conditioned upon the understanding that all records, data, and information obtained by the Commonwealth shall be used only for the purposes of determining my fitness for the volunteer position(s) to which I am assigned.

Name and Address

Prefix:

Example: Dr., Col., Mr., Mrs., Ms.

First Name:

Middle Name:

Last Name:

Suffix:

Example: Jr., Sr., MD., PhD, RN

Address Line 1:

Address Line 2:

City:

State:

County:

Zip Code:

Work State:

Identifying Information

Contact Information

Primary Email Address

Delete

Email Address:

If you have an email account, it is important for you to provide this information. Without your email address, you may miss important messages and notifications. Please note that the system will not allow two accounts with the same email address. If you do not have an email address or your email address is already registered with the system, you can learn more about obtaining a free email address by clicking here.

Confirm Email Address:

Add Email Address

Contact Method 1

Delete

Contact Method 1:

Number to Attempt:

x

Pager Type:

Pager Carrier:

Pager ID/PIN:

Add Another Contact Method

Occupation Information

What is your occupation type?

Occupation:

If your occupation does not appear in the list, please select Other.

What is your current professional status for this occupation?

Criminal Offense

Required field Have you ever been arrested or convicted of any criminal offense?

Yes No

(Traffic or citation only offenses are not required to be reported.)

If yes, please mail a copy of court-issued documents for each offense, which must include the following information, to the Volunteer Emergency Workforce Coordinator, PA Department of Health, Bureau of Public Health Preparedness, 130A Kline Plaza, Harrisburg, PA 17104.

Type of each offense
Date of each offense
County and state where each offense was committed
Current case status or final disposition for each offense

This information must be postmarked within two weeks of completing your registration in SERVPA. The Department will review your submission and notify you if further information is required. If your SERVPA registration is disapproved as a result of your criminal history, the Department will notify you and your access to the SERVPA system will be terminated.

Criminal activity is not an automatic rejection of an individual’s approval to volunteer. The Department will disapprove your SERVPA registration if you withhold required information or provide false information about your criminal history and your access to the SERVPA system will be terminated.

Registration Feedback

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