MADISON COUNTY HEALTH DEPARTMENT MEDICAL RESERVE CORPS

Public Health Emergency Volunteer Application

For Medical and Non-Medical Volunteers *** (Note: complete both pages)

                                                                         Registrant Information                                                                                  

Last Name:    First Name:    Middle:   

Home Address:        City:    State:    Zip Code:   

Business Address:  City:    State:    Zip Code:   

Home Phone:   Business Phone:   Cell Phone:   Fax Number:

Email Address:

                                                                             Current Employment                                                                                  

Employer Name:    Length of Employment:   

Position / Title:

Employer Address:  City:    State:    Zip Code:   

                                                                                  Experience                                                                                            

Organization Name:    Address:   Phone:

From:  To:   Supervisor's Name/Title:   


Organization Name:    Address:   Phone:

From:  To:   Supervisor's Name/Title:   


Prior Disaster Relief Experience:

Prior or Current Volunteer Experience:

                                                                                Current Licenses                                                                                     

Type:    Number:    State:    Expiration Date:

Type:    Number:    State:    Expiration Date:

                                                            Language Skills (Include Sign Language):                                                                 

Language Skills:

                                                                          Volunteer Opportunities                                                                               

I am registered with other volunteer/emergency disaster systems
List:

Check activities which interest you or skills you possess:
Administration           Development           Translating Languages:
Clerical                       Disaster Education                   
Consulting                 Marketing                  Youth Programs
Communications      Public Relations     Other: 

                                                                                  Availability                                                                                            

Monday                Tuesday                Wednesday                Thursday                Friday                Saturday                Sunday
Anytime
Prefer continuous duty                Prefer duty on separate days

                          Please Indicate the Duration and Distance to Which You Could Commit if Activated                                   

25 miles of home                25-50 miles                50-100 miles                Distance is not an issue                Other               

Statewide                      Geographic preference:

8 hours                16 hours                24 hours

                                                                    Emergency Contact Information                                                                         

Name:        Relationship:

Home Phone:         Work Phone:


Name:        Relationship:

Home Phone:         Work Phone:

                                                                             Medical Information                                                                                  

Describe any restrictions on your activities (physical, medical, mental):


Immunizations:

Date of last tetanus shot:    Other immunizations (smallpox, etc):

                                                                             Personal Information                                                                                 

I am licensed to operate a motor vehicle in this state and I carry auto insurance

I am currently charged with a felony or I have been convicted of a felony in the past


Volunteer Agreement
     1. The information provided is complete and true. If information given on this application is incomplete or untrue, I understand
          my assignment may be terminated.
     2. I have disclosed any felony convictions. I agree to a background check, verification of the statements contained herein and
          additional screening procedures.
     3. I understand that my own insurance will be used as coverage for illnesses and injuries and that I am ultimately responsible
          for any costs incurred.
     4. I agree to respect the rights, property and confidentiality of emergency workers and individuals affected by disaster.
     5. I agree to adhere to the rules/instructions of my job assignment(s) so as not to jeopardize relief operations or procedures.
     6. I agree to uphold the mission of the health agency in the event of a disaster.

Volunteer Signature:            Date:




Host Agency:   Madison County Health Department
Health Department Signature:            Date:
                                              Title:


Please confirm by correctly answering the following security question:
What does 1+1 equal?

               

OR

Print and Mail Completed Form to:
Debra M. Tscheschlok, R.N., B.S.N.
Madison County Health Department
101 East Edwardsville Road
Wood River, IL 62095


Questions: Call ERC Debra at 618-296-6080 or Secretary Dola at 618-296-6059
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