Martha

Martha’s Vineyard Medical Reserve Corps

Volunteer Application

Personal Contact Information

Dr. Mrs. Mr. Ms.

Last Name____________ First Name__________ MI ______(Circle one above)

Home Address ___________________________________ Apt. #_____________

City _____________________ State______________ Zip Code_______________

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

E-mail Address___________________________ Personal Pager # (____ )___________________

Business (Mailing) Address:____________________________________________

City___________________________ State_________ Zip Code_______________

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 NO

Please check one of the following volunteer opportunities that best describe 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 any other organization? (e.g. American Red Cross, CERT, 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_________________________________________________________________________

❏ Blood borne 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

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 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.

_________________________________________ Date:_______________________

Please send Application to:

Jennifer Randolph, MRC Coordinator

Martha’s Vineyard Medical Reserve Corps

9 Airport Road, RR #1, Box 860

Vineyard Haven, MA 02539