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Springfield MA Forecast
Friday Mar 12, 2010

Thank you for your interest in volunteering. Please complete our Volunteer Application Form, below. After submitting the application you will need to print and sign the CORI verification form (link at left) and mail it to the address indicated on the printed form.

Please note that the form has several "tabs."  The first and last tabs, in red, are required.

Form fields with are required.

 
Contact Information:
First Name: 
Middle Initial
Last Name: 
Street Address:
City/Town:
State & Zip: State:    Zip code:
Email:
Home Phone: (nnn-nnn-nnnn)  
Work Phone: (nnn-nnn-nnnn ext xxx)
Mobile number: (nnn-nnn-nnnn)
Best way to contact you:
Date of Birth: 
MRC Assignment:
All volunteers are affiliated with a local MRC.  You can choose your MRC by selecting one from the list below.  If you prefer, we will assign you to the MRC that covers your home address/zip code.
Please select an MRC
Professional Information:
Work Status: 
Employer: 
Occupation: 
 
Do you have a current Massachusetts Drivers' License? YES  NO 
Drivers License num:
State Issued:
Exp Date:
(mm/dd/yy)
 
Medical License?
Type:
Number:
Issue Date:
(mm/dd/yy)
Exp Date:
(mm/dd/yy)
Professional Skills
Professional areas of specialty or skills that would benefit the MRC:
First Aid Certified? YES  NO  If yes, expires:
(mm/dd/yy)
CPR Certified? YES  NO  If yes, expires:
(mm/dd/yy)
Teaching experience? YES  NO 
Any other emergency/disaster response team or alert systems? YES  NO 
If yes, please list:
 
Other Information:
Would you be interested in leadership positions within the MRC?  YES  NO
Please choose one of the following volunteer opportunities that best describes how you would like to participate in the MRC Program.
MRC Basic Member
1. Activated only in case of a local emergency
2. Notified of trainings and drills
MRC Active Member
1. Activated for local emergencies
2. Called to help with special projects and events
3. Notified of trainings and drills
MRC Team Leader Member
1. Activated for local emergencies
2. Called to help with special projects and events
3. Notified of trainings and drills
4. 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
Would you also be interested in being a member of the Massachusetts System for Advanced Registry (MSAR)? 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 state)
  YES  NO
Check your availability. Sun Mon Tues Wed Thurs Fri Sat

Morning Afternoon Evening Anytime
Language 1 Skills:
Other:
Speak (10 = best)
Understand (10 = best)
Language 2 Skills:
Other:
Speak (10 = best)
Understand (10 = best)
Language 3 Skills:
Other:
Speak (10 = best)
Understand (10 = best)
 
Emergency/Contact Medical Information: (optional)
Emergency Contact:
Relationship:
Address:
Home Phone:
Other number:   Work Cell Pager Fax
Medical conditions or information we should know about: (optional)
 
Allergies:
Do you carry: EPI-Pen YES NO
  Glucometer YES NO
 
I agree to participate in required trainings.
I agree to a Criminal Offender Record Information (CORI) Check and a Sex Offender Registry Information (SORI) check.
I agree to read and abide by guidelines set in the MRC Policy and Procedures Manual.
I agree to sign the MRC Code of Conduct.
I agree to sign the MRC Confidentiality Agreement.
I agree to sign a release form.
I authorize the verification of the information provided on this form.

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 type your name in lieu of signature below.