WMMRC - Volunteer Application

Thank you for your interest in volunteering.
Please complete our Volunteer Application Form. After submitting the application, you will need to print and sign the CORI verification form and mail it to the address indicated on the printed form.
Items with red dot

are required.

Contact Information:

First Name: red dot

MI: Last Name: red dot

Street Address:

City/Town: red dot

State: Zip code: red dot

Mailing Address (if different from above):

City:

State: Zip code:

Home Phone: red dot

(nnn-nnn-nnnn) Email: red dot

Work Phone:

(nnn-nnn-nnnn ext xxx)

Other number:

(nnn-nnn-nnnn)

Cell/mobile phonePagerFax

How would you like us to contact you?

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: red dot

Medical Licenses:

Medical License 1:

type: number:

Issue Date: (mm/dd/yy) Exp Date: (mm/dd/yy)

Medical License 2:

type: number:

Issue Date: (mm/dd/yy) Exp Date: (mm/dd/yy)

Medical License 3:

type: number:

Issue Date: (mm/dd/yy) Exp Date: (mm/dd/yy)

Professional areas of specialty or skills that would benefit the MRC:

You have characters left.

Are you First Aid Certified?

YES NO If yes, expires (mm/dd/yy)

Are you CPR Certified?

YES NO If yes, expires (mm/dd/yy)

Do you have teaching experience? YES NO

Are you part of any other emergency/disaster response team or alert system? YES NO

If yes, please list:

Other Information:

Do you have a current Massachusetts Drivers' License? YES NO

Drivers License #: State Issued: Exp Date: (mm/dd/yy)

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

Please check your availability. Check all that apply.

Language Skills:

Language 1: Other, please specify
Speak Understand

Language 2: Other, please specify
Speak Understand

Language 3: Other, please specify
Speak Understand

Emergency/Contact Medical Information: (optional)

Emergency Contact:

Relationship:
Address:
Home Phone:
Other number:	WorkCell/mobile phonePagerFax

Medical conditions or information we should know about: (optional)

Allergies:
Do you carry:	EPI-Pen YES NO
	Glucometer YES NO

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.

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	last updated: January 2008