Kern Medical Reserve Corps (KMRC) Online Volunteer Registration Form

bolded fields are required

CONTACT INFORMATION

First Name:    Middle Initial:    Last Name: E-mail:   Confirm E-mail:

Phone numbers - in order of preference: Phone Number Type   Phone # -- select -- home work cell pager -- select -- home work cell pager -- select -- home work cell pager -- select -- home work cell pager FAX Residence Address:   Street: City: , CA   ZIP Code: Mailing Address (if different): Street: City: , CA   ZIP Code:

Emergency Contact:   Name  Phone number  Relationship

BACKGROUND INFORMATION

Current Employer:   Position:

Previous relevant position(s) (paid and volunteer)

Do you currently serve as a disaster-response volunteer?  Yes    No

If so, please list the organization(s):

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

License Type  State Where Issued     License #  Expiration Date

Do you have prescriptive authority?  Yes  No

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

SKILLS

Languages spoken (other than English) Language Speaking Reading Writing -- Select Your Skill Level -- excellent fair poor -- Select Your Skill Level -- excellent fair poor -- Select Your Skill Level -- excellent fair poor -- Select Your Skill Level -- excellent fair poor -- Select Your Skill Level -- excellent fair poor -- Select Your Skill Level -- excellent fair poor

Please list any other certificates, training or skills you bring to the KMRC:

VOLUNTEER PREFERENCE:

Licensed Medical Services

Non-licensed Medical Services

Mental Health/Counselors/Chaplains

Site Support (includes people who greet the public, do routine clerical work, assist with parking and security, stock supplies, run errands, do computer work, etc.)