Morris County MRC Medical Volunteer Application

Personal Information

First Name

Middle Initial

Last Name

Date of Birth

Street Address

City

State

Zip Code

Enter at least one phone number:

Cell Phone Number

Cell Phone Carrier

Home Phone

Do you currently serve in the National Disaster Medical System?

Yes

Do you possess a valid driver's license?

Yes

Are you at least 18 years old?

Yes

Are you a U.S. citizen?

Yes

Employment Information

Place of Employment

Work Street Address

Work City

Work State

Work Zip Code

Work Phone Number (with extension)

Emergency Contact

Contact's First Name

Contact's Last Name

Relationship

Contact's Street Address

Contact's City

Contact's State

Contact's Zip Code

Enter at least one phone number for your emergency contact:

Contact's Cell Phone Number

Contact's Cell Phone Carrier

Home Phone

Work Phone

Additional Information

Languages you are fluent in

Languages you can read/write

Do you have any special needs or restrictions? If so, please explain:

If you have committed to any other organization or institution, by virtue of employment or volunteerism, in the event of the public health emergency, please explain:

Professional Licensure, Certification, Specialties and Experience

Has your professional license or certification ever been suspended or revoke in New Jersey or any other state?

Yes in NJ

Yes in another state

Name on License/Certification

License/Certification Number

State on License/Certification

License Type

Status

Speciality within the above professional licensure/certification that you possess:

Sub-specialty within the above professional licensure/certification that you possess:

Skills

Training/Continuing Education

Expectation of NJ Medical Reserve Corps Professional Health Volunteers

As a volunteer with the New Jersey Medical Reserve Corps, I will be called upon to assist in the event of a public health emergency. I agree to attend an education program to explain my role in disaster preparedness; I will be assigned duties based on my level of training and experience. I understand that submitting this application does not guarantee acceptance into the NJ Medical Reserve Corps. The information contained in this application is, to my knowledge, truthful. I agree to serve my fellow citizens to the best of my professional ability.

I agree to the above statement. Failure to agree to the above statement invalidates application.

Yes

Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.