LICENSED MEDICAL        NON-LICENSED MEDICAL                 NON-MEDICAL

Last                                       First

Name                                    Name

Sex      Height

Weight     Eye color

Street Address (Mailing)

        Maiden name

City

State

Zip

Home Phone

Work Phone

Cell Phone

Home Email

Employer Name:

Work Email

Alternate E-mail:

Employer Address:

Employer Phone:

Type - Professional:

q  Doctor 

q  Nurse

q  Dentist

q  Pharmacist

q  Psychiatrist

q  Veterinarian

q  O/T

q  P/T

q  ASL

q  Mental Health

q  Social Worker

q  EMT

q  Non Medical

q  Computer / IT

q  Other

   Please describe:

Emergency contact information:

Name:______________________________

Address:____________________________

City: _______________________________

State: ____                 ZIP: ______

Phone: (      ) ________ - _______________

Cell:     (      ) ________ - _______________

Relationship:

Last                                               Name:_______________________

First

Name:_________________________

License Information:

State(s) Held:

(1)______ (2)________ (3)________

License Number(s):

(1)_______(2)__________ (3)___________

License Expiration Date(s):

(1)________  (2)__________ (3)___________

Language/s:

Drivers License Number:

Drivers License

State of Issue:

Drivers License

Expiration date:

Level of Participation Desired:  I prefer to be:  (circle one)         ACTIVE                        LIMITED

ACTIVE:  Receive notifications of ALL training opportunities, training drills & exercises, emergency                events, as well as Non-emergency volunteer opportunities

LIMITED:  Receive only notification of training drills & exercises and all emergency events

Volunteer Interests: Circle all that apply:

Administration     Public Safety        Phone Bank        Steering Committee          Clinical

Newsletter     Volunteer Coordination       Behavioral Health      Deliveries     Clerical       Web Site                                                 Training Fundraising    Database

A Criminal and Sexual Background Check is required of all volunteers:

I do hereby give the  Eastern Panhandle Medical Reserve Corps permission to release personal information with local, state and federal emergency management agencies and other Health and Human Service agencies as needed.

Date of Birth _____/_____/_____  Social Security #_______- _______- ________     (requested but not required)

Volunteer Signature ___________________________________________________       Date_____/_____/_____

Location Preference for Responding: Check all that apply:

Signature of EPMRC Authorized Employee  and Title                                      

Date