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2. Volunteer Information
   Please include as much information as possible.
4. Name
5. Email Address
7. Address Line 1
9. Address Line 2
11. City
12. State
13. Zip Code
15. Home Number
16. Cell Number
18. Office Number
19. Pager Number
23. Licenses or Certifications Held
    Please include numerical designations.
25. Type of Licenses or Certifications
27. State of Licenses or Certificates
29. Are Licenses or Certifications current?

    1. Yes
    2. No
31. Areas of Interest

    1. Disaster Preparedness/Bioterrorism (includes shelter operations and immunizations)
    2. Vulnerable Populations (Disabled Populations)
    3. Emergency Mental Health
    4. Community/Public Education Programs
    5. Other
33. Other areas of interest
37. Training & Education
39. Are you current in Cardiopulmonary Resuscitation?

    1. Basic Yes
    2. Basic No

    1. Advanced Yes
    2. Advanced No
41. What others areas would you like to receive training in?
43. Are you currently serving in a recall capacity for any other group or organization?

    1. Yes
    2. No
45. Names of groups or organizations
49. Verification and Consent for Reference and Background Check
    I verify that the above information is accurate to the best of my knowledge. I give the Medical Reserve Corps of Onslow County permission to inquire into my educational background, licenses, police records, and employment and/or volunteer history. I also give permission to the holder of any such information to release it to the Medical Reserve Corps of Onslow County. I hold the Medical Reserve Corps of Onslow County harmless of any liability, criminal or civil, that may arise as a result of the release of this information about me. I also hold harmless any individual or organization that provides information to the above-named agency. I understand that the Medical Reserve Corps of Onslow County will use this information only as part of its verification of my volunteer application.
51. Name
53. Signature
54. Date
    Date
56. Parent's Signature (if under 18)
58. Please print return application to:
    Medical Reserve Corps of Onslow County
    1180 Commons Drive North
    Jacksonville, NC 28546
    Fax: 910-455-6767
60. Thank you for your willingness to help your community be a safer place to live.
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

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