If you would like to participate in the MRC, please fill out the registration form below. We ask that you complete as much information as possible.
* denotes required field
Please enter your current Employment and Professional information below where applicable.
Please select the level of MRC participation you wish to fullfill.
Please select all roles you have interest in fullfilling.
Please enter information for the individual you wish to be contacted in the event of an emergency.
A Criminal and Sexual Background Check is required of all volunteers
I do hereby give Region V Medical Reserve Corps permission to release personal information with local, state and federal emergency management agencies and other Health and Human Service agencies as needed.
Date of Birth:* (MM/DD/YYYY)
This information is requested by Region V Medical Reserve Corps and is for the purpose of organizing volunteers and staff to respond to public health emergencies. It will not be utilized or released for any other purpose without your express written permission unless required by law and all information will be kept in a secure manner.
I understand and agree to the MRC Privacy Act Statement
If you have any questions regarding this form, please contact Kurt Kuchle by phone at (815) 872-5091 ext 216, by fax at (815) 872-5092 or by email at email@example.com