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MRC Online Volunteer Application

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

Personal Information
Name:*

Street Address:*

City:*

State:*

Zip Code:*

Phone:* (XXX-XXX-XXXX)

Work Phone: (XXX-XXX-XXXX)

Cell Phone: (XXX-XXX-XXXX)

Email:*

Current Employment Information

Please enter your current Employment and Professional information below where applicable.

Employer:

Profession:
Doctor
Nurse
Dentist
Pharmacist
Psychiatrist
Veterinarian
Mental Health
Social Worker
EMT
Other
If Other, please describe!

License/Certificate/Registration #:

State License Held:

Expiration Date: (MM/DD/YYYY)

Languages:

Participation Role:

Please select the level of MRC participation you wish to fullfill.

ACTIVE - Receive notifications of ALL training opportunities, training drills & exercises,emergency events, as well as non-emergency volunteer opportunities
LIMITED - Receive only notification of training drills & exercises and all emergency events

Volunteer Interests:

Please select all roles you have interest in fullfilling.

Administration
Public Safety
Clinical
Fundraising
Database
Volunteer Coordination
Behavioral Health
Distribution
Clerical Help

* denotes required field

Emergency Contact Information

Please enter information for the individual you wish to be contacted in the event of an emergency.

Name:*

Street Address:*

City:*

State:*

Zip Code:*

Phone:* (XXX-XXX-XXXX)

Cell Phone: (XXX-XXX-XXXX)

* denotes required field

Background Check Authorization*

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)

* denotes required field

Privacy Act Statement*

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

* denotes required field

Sign and Submit Signature:*

Date:*
   

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 kkuchle@bchealthdepartment.org