Health Department

Mineral County

If “Yes,” complete details below. Please note that conviction is not an automatic bar to placement. Each case is considered individually. Please include: Offense(s), place(s), date(s), and penalty(s):

Convictions: As an adult, have you ever been convicted of a crime by any court? (Omit minor traffic violations): *

Yes

If yes, please list:

Are you part of an emergency/disaster plan with any other organization? (Such as the American Red Cross, hospital, etc.) *

Yes

Read:

Yes

Level of Fluency (choose one):

Excellent

Fair

Poor

Skills - What languages do you speak or understand other than English? Please list and indicate level of fluency (Include sign language):

I understand that my credentials / licenses (if applicable) will be verified. *

Please fill out the online application below and we will be in contact with you soon.

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Volunteer Guidelines and Provisions: State law provides specific immunities during your service in a declared disaster and The Board of Supervisors may authorize certain insurance provisions to the benefit of MRC volunteers. Any such coverage will be provided in detail to volunteers prior to their service as a MRC volunteer. Mineral County MRC and its officers, employees and agents shall not be held liable for any death, injury or property damage claims arising from volunteer work. If any claim arises out of the foregoing, the volunteer shall defend, indemnify and save harmless Mineral County MRC and its officers, employees and agents from same. By clicking submit, I hereby certify that all statements contained on this application are true to the best of my knowledge. I understand and agree to the above volunteer guidelines and provisions. *

Medical Reserve Corps (MRC) Membership Directory: I authorized the following information to be published in the directory. This directory will be distributed to MRC Membership and Advisory Council only. *

Name

Address

Phone - Home

Phone - Work

Phone - Mobile

Suffix: MD, RN, NP, RPh, Other

Level of Involvement (check all that apply): *

CE/Training Opportunities

Actual Emergencies - Local Disaster Exercises

Actual Emergencies - Out of the County

Public Health Clinics

Certifications & Training Completed:

Write:

Yes

License (Professionals with a current license or certification in any health or mental health field):

Phone - Mobile: *

Phone - Work: *

Date of Birth: *

Address: *

Prefix: *

Mr.

Ms.

Mrs.

Dr.

Name: *

Email: *

Phone - Home: *

Do you have prescriptive authority?

Yes

Preparedness Services

Medical Volunteer Corps Application

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