Date of Birth
Enter at least one phone number:
Do you currently serve in the National Disaster Medical System?
Do you possess a valid driver's license?
Are you at least 18 years old?
Are you a U.S. citizen?
Enter at least one phone number for your emergency contact:
Do you have any of the following skills?
Have you completed any training or continuing education programs in the following areas?
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.