City of Springfield, MA Health and Human Services MRC

Applicant Information

Name:

Home Phone:

Current address:

Work Phone:

City:

State and ZIP:

Mobil Phone:

Email Address:                                                Date of Birth:

Social Security #:

PROFESSIONAL INFORMATION

Profession/occupation, and or degrees:

Do you hold Massachusetts health-related license/certifications?

  Yes       No

If yes: title and #:

Do you hold other relevant license/certifications e.g. Ham radio?

  Yes       No

If yes: title and #:

Current Employer (if applicable): Name and address phone or email.

Professional area of specialty or skills:

Do you have First Aid Certification?

  Yes       No

If yes provide a copy of your card.

Do you have CPR Certification?

  Yes       No

If yes provide a copy of your card.

Do you have Teaching Experience?

  Yes       No

Explain:

Do you have a MA driver’s license?

  Yes       No

Are you fluent in any languages other than English?

  Yes       No

Specify:

Are you a member of another emergency/disaster response organization?

  Yes       No

Circle: (Red Cross, CERT, MSAR, Local Fire Dept)

Other Specify:

Please list skills not listed above. Use back of sheet, if you need more space.

If you are a student, please list your major and year of graduation:

anticipated MRC involvement

What level of involvement interests you?

  Tier 3 All activities and trainings

  Tier 2 Some activities and trainings

  Tier 1 Volunteer only in an emergency

Are you interested in a leadership position within the MRC unit?

  Yes       No        Maybe

During an emergency, where would you be willing to volunteer?

  Locally

  Regionally

  Statewide

  Nationally

agreements and Signature

  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.

COMMENTS

Signature of applicant:

Date: