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Medical Reserve Corps of Onslow County Registration Form

  1. Volunteer Information
    Please include as much information as possible.
  2. Licenses or Certifications Held
    Please include numerical designations.
  3. Are Licenses or Certifications current?
  4. Areas of Interest
  5. Training & Education
  6. Are you current in Cardiopulmonary Resuscitation?
  7. Are you currently serving in a recall capacity for any other group or organization?
  8. 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.
  9. Please print return application to:
    Medical Reserve Corps of Onslow County
    1180 Commons Drive North
    Jacksonville, NC 28546
    Fax: 910-455-6767
  10. Thank you for your willingness to help your community be a safer place to live.
  11. Leave This Blank:

  12. This field is not part of the form submission.