Medical Volunteer Corps

MVC Application

Write:

Yes

Read:

Yes

Write:

Yes

Level of Fluency (choose one)

Excellent

Poor

Fair

Volunteer Guidelines and Provisions: State law provides specific immunities during your service in a declared disaster and The Board of Supervisors may authorize certain insurance provisions to the benefit of MRC volunteers. Any such coverage will be provided in detail to volunteers prior to their service as a MRC volunteer. Hampshire County MRC and its officers, employees and agents shall not be held liable for any death, injury or property damage claims arising from volunteer work. If any claim arises out of the foregoing, the volunteer shall defend, indemnify and save harmless Hampshire County MRC and its officers, employees and agents from same. By clicking submit, I hereby certify that all statements contained on this application are true to the best of my knowledge. I understand and agree to the above volunteer guidelines and provisions. *

If “Yes,” complete details below. Please note that conviction is not an automatic bar to placement. Each case is considered individually. Please include: Offense(s), place(s), date(s), and penalty(s):

Convictions: As an adult, have you ever been convicted of a crime by any court? (Omit minor traffic violations) *

Yes

Comments

Are you part of an emergency/disaster plan with any other organization? (Such as the American Red Cross, hospital, etc.)

Yes

Medical Reserve Corps (MRC) Membership Directory: I authorized the following information to be published in the directory. This directory will be distributed to MRC Membership and Advisory Council only. *

Name

Address

Phone - Home

Phone - Work

Phone - Cell

Suffix: MD, RN, NP, RPh, Other

Preferred Method of Communication for Routine Matters (Please check one) *

US Postal

Mail

Level of Involvement (check all that apply) *

CE/Training Opportunities

Actual Emergencies – Local Disaster Exercises

Actual Emergencies – Out of the County

Public Health Clinics

Certifications & Training Completed

Read:

Yes

Level of Fluency (choose one)

Excellent

Poor

Fair

Language Spoken

Skills - What languages do you speak or understand other than English? Please list and indicate level of fluency: (Include sign language)

I understand that my credentials / licenses (if applicable) will be verified.

Do you have prescriptive authority?

Yes

License (Professionals with a current license or certification in any health or mental health field)

Phone - Mobile *

Phone - Work *

Email: *

Check here to receive email updates

Name: *

Prefix *

Mr.

Ms.

Mrs.

Dr.

Address *

Date of Birth *

Phone - Home *

Medical Volunteer Corps Online Application

Preparedness Services

Health Department

Hardy County

Medical Volunteer Corps Online Application

Preparedness Services

Health Department

Location

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