MRC Registration Form

MRC Registration

Mahoning/Columbiana Medical Reserve Corps Volunteer Application
 

Personal Information

 
Name

First Name *

Last Name *

Middle Initial

Date of Birth *
(YYYY-MM-DD)

Home Address

Street Address *

Address Line 2

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Work Address

Street Address

Address Line 2

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Home Phone

Cell Phone

Work Phone

Pager

Email

Emergency Contact Information - To be notified in case of an emergency

First Name *

Last Name *

Relationship

Street Address *

Address Line 2

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Phone *

License, Permissions and Checks

Health Issues? *
Do you have any personal health issues that would impact your ability to volunteer? (For example allergies, medication issues, disabilities, special needs, or being treated for a medical condition). If Yes, you will be asked to provide an explanation.
YesNo

Licensed Professional?*
Are you an Ohio licensed professional? If yes, you will be asked to fill out details regarding your Medical Profession, Medical Specialty, Medical License Number and License Expiration Date. This section is required for liability protection as a Medical Reserve Corps volunteer:
YesNo

Photo Permission
By checking the box below I am giving my permission to be photographed for publicity purposes. I understand that this information may appear publicly in a newspaper or other advertising media. No expiration on this permission unless notified.
Yes

Have you ever been convicted of a felony? *
YesNo

Have you ever been convicted of a misdemeanor other than a traffic violation? *
YesNo

Perform Background Check *
A Criminal Background Check may be required of some volunteers - may we perform a background check on you? By selecting Yes, you agree that a background check may be performed. If needed you will be provided an area to supply Other Names you may want us to use durning this check. By Selecting NO, you agree that do not wish to have a background check performed. Refusal of a background check does not automatically eliminate you from consideration for volunteer service.
YesNo

Final Details and Submission

State of Ohio Data Base

I understand that by voluntarily providing my information to the Ohio Citizen Corps and the Ohio Medical Reserve Corps, I am indicating a willingness to volunteer during a governmentally declared emergency that requires assistance from the medical community.

Registering with the Ohio Citizen Corps and the Ohio Medical Reserve Corps is not a substitute for the appropriate professional license to practice in Ohio. I understand that it is my responsibility to properly maintain my professional license in good standing and that an Ohio license in good standing and participating in any required training or education is a prerequisite to volunteering.

I further understand that by saying "Yes" I hereby certify and affirm all the information I have provided is true and accurate to the best of my knowledge.

I also acknowledge that the Ohio Citizen Corps and the Ohio Medical Reserve Corps may verify the information I have provided as a part of the volunteering process.

The Ohio Citizen Corps Database is maintained by the Ohio Community Service Council. We are entering your information in this database for you. You are encouraged to use your account we are setting up for you at www.servohio.org The site is set up to allow you to keep your own information current and customize your volunteer experience. Response is ALWAYS completely voluntary.

Self Attest *
YesNo

Signature *
Please type your Full Name in the box below

Today's Date *
(YYYY-MM-DD)