Volunteer Application

 

 

 

Personal Contact Information

 

                                                                                         Dr.   Mrs.   Mr.  Ms.

Last Name____________   First Name__________ MI (Circle one above)

Home Address:   Street_____________________________   Apt. #_____________

City  _________________ State_________________ Zip Code___________

Home Phone # (___)__________ Cell Phone # (___)____________ Work Phone # (___ )_________

E-mail Address___________________________ Personal Pager # (____ )____________________

Fax (_____)___________    Business (Mailing) Address:__________________________________

City____________  State____ Zip Code________ Business Phone # (____)_________

 

In case an emergency happens to me please contact:

Name:________________________ Relationship:______________

Daytime phone number:_______________  Evening phone number:________________

 

Although the focus of our unit is on local emergencies, would you like us to call you in case of a statewide or national emergency
(such as Hurricane Katrina relief efforts in 2005)?  Please circle any that apply:

 

National           Statewide          Region         My town only

 

Would you be interested in leadership positions within the MRC?     YES spacer  NO spacer 

 

Please check one of the following volunteer opportunities that best describes how you would like to participate in the MRC Program.

 

_____ MRC Emergency Team Member (Activated only in case of local emergency, notified of trainings and drills)

 

_____ MRC General Team Member (Activated for local emergencies, called to help with   special projects and events, notified of trainings and drills.)

 

_____ MRC General Team Leader Role (Activated for local emergencies, called to help with special projects and events, notified of trainings and drills,
administrative and clerical duties.)

 

Would you also be interested in being a member of the National MRC Auxiliary?  This group can be activated as part of a local team to respond to
State and National emergencies.  (Extra training and credentialing required by the Surgeon General's Office)                Yes    No 

 

 

For applicants interested in volunteering for non-emergency assignments, what hours do you prefer?

 

____ Weekday mornings _____ Weekday afternoons _____ Weekday evenings

____ Weekend mornings _____ Weekend afternoons _____ Weekend evenings

 

Are you part of an emergency/disaster plan with any other organization? (Such as the American Red Cross, a local hospital, etc.)   If yes, please list below. Yes No

 

________________________________________________________________________________

 

Who would you respond to first if on multiple lists? ________________________________________________________________________________

 

 

If volunteers are needed for response to an emergency during the hours when you’d be working, is it ok to contact you at your place of employment?    Yes No

 

If yes please provide the following information:

Occupation (check) :           ❏ Full Time ❏ Part Time ❏ Retired ❏ Student

Employer Address______________________________________________________

General Phone Number (___)________Your extension________ Fax #(___)________

Education (check highest level):      ❏ High School ❏ College ❏ Graduate School ❏ Other

School Name:_____________________ Location:______________________________

Type of Degree:_____________Major/Specialization:_________ Year Graduated:_____

 

License (Professionals with a current license or certification in any health or mental health field)

Circle all applicable:                                   License/Certification #                         Expiration Date

1. M.D./ D.O.____________________________________________________________________

 

2. D.V.M./ V.M.D._________________________________________________________________

 

3. D.D.S./D.M.D.__________________________________________________________________

 

4. D.C.__________________________________________________________________________

 

5. R.N.__________________________________________________________________________

 

6. L.P.N._________________________________________________________________________

 

7. EMT/ Paramedic_________________________________________________________________

 

8. P.A/ N.P._______________________________________________________________________

 

9. Pharmacist_____________________________________________________________________

 

10. Psychiatrist/Psychologist__________________________________________________________

 

11. Other Mental Health Practitioner____________________________________________________

 

12. Social Work LSCSW LMSW LBSW_________________________________________________

 

13. Other health related degrees or licenses_____________________________________________

 

14. Do you have prescriptive authority?                           Yes              No

 

Have you ever had your professional license suspended or revoked?  Yes    No

(Please attach letter of explanation)

 

Certifications & Training (Check any that apply)

 

Certifications                        Most Recent Date                            Certifying Agency

❏ CPR______________________________________________________________________

❏ First Aid___________________________________________________________________

❏ Disaster Training_____________________________________________________________

❏ CERT______________________________________________________________________

❏ Bloodborne Pathogens &

Standard Precautions____________________________________________________________

❏ Military Medical Training________________________________________________________

 

Training (Check/circle any that you have attended)

❏ Incident Command System100/200 other              ❏ Other Training (list below)

❏ NIMS-700                                                              ________________________________

❏ Epidemiology                                                          ________________________________

❏ Bioterrorism                                                                        ________________________________

❏ Terrorism & emergency response to terrorism     ________________________________

 

Languages

What languages do you speak or understand other than English? Please list and indicate level of fluency: (Include sign language)

Languages spoken:                            level of fluency (circle one)                 Read and write?

____________________                          Excellent   Fair  Poor                       Yes  No

____________________                          Excellent   Fair  Poor                       Yes  No

 

Volunteer Interests

Please check any fields of interest listed below:

Clinical Work ____      Deliveries ____ Fundraising___   Administration ____ Health Education _____ Newsletter Production____ Phone Bank ____  Volunteer Coordination________

 

 

Personal Health

Do you have any personal health issues that would impact your ability to volunteer? Yes   No

(For example allergies, medication issues, disabilities, special needs, or being treated

for a medical condition)

 

If yes, please either list here or speak personally with the MRC Coordinator.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

References: Please list three references who are familiar with your qualifications/experience. Do not list relatives.

Name _______________________________                       Phone Number________________

Address____________________________________________________________________

Name ________________________________                     Phone Number_______________

Address____________________________________________________________________

Name ________________________________                     Phone Number_______________

Address____________________________________________________________________

 

All of the information that I have supplied is correct to the best of my knowledge.  I do hereby give my local Medical Reserve Corps (MRC) permission to make inquiries concerning my educational background, references, driving record, present and previous employment, licenses, certifications and police record.  I further give permission to the holder of any such records to release the same to the MRC.  I hold the MRC harmless of any liability, whether civil or criminal, that may arise as a result of the release of the information about me.  I also hold harmless any individual, agency, business or corporation that provides information to the MRC.  I recognize that I should investigate my personal and business liability coverage as pertains to my volunteer work for the MRC.  I recognize that prior to being accepted as a MRC volunteer, I may be required to provide additional documentation as proof of certain certifications (CPR, First Responder, CDL, etc.)

 

I understand that I am a volunteer and will not be paid for any of my services.

I give my permission for the MRC to release personal information to local, state and federal emergency management I give my permission for the MRC to release personal information to local, state and federal emergency management agencies and
other Health and Human Service agencies as needed.

 

Be sure this box is checked if you accept these terms, and sign your name below.

 

 

_________________________________________

 

 

Please send Application to:

Lynda C. Costa, MRC Volunteer Coordinator

Barnstable County Dept. of Health & Environment

P.O. Box 427, 3195 Main Street

Barnstable, MA 02630