Eastern Shore Medical Reserve Corps (ESMRC)

Last Updated: 2-December-2008

* Denotes Required Field

VOLUNTEER INFORMATION:
First Name:*		Last Name:*
Address:*
Address 2:
City:*
State:*
Zip:*

CONTACT INFORMATION: Please include as much information as possible.

Home Phone:*		Office Phone:
Cell Phone:		Pager Number:

Email Address:
Emergency Contact Name:
Emergency Contact Phone Number:

LICENSES OR CERTIFICATIONS:

Type:	No:	State:	Current:	YES NO
Type:	No:	State:	Current:	YES NO
Type:	No:	State:	Current:	YES NO
Type:	No:	State:	Current:	YES NO

TRAINING AND EDUCATION:

Are you currently certified in the following areas?

CPR:	YES NO	Type of Certification:		Expiration Date:
First Aid:	YES NO	Type of Certification:		Expiration Date:

Please list any additional training you would be interested in?

Are you currently committed to another organization in emergency situations?

YES NO

If yes, please list:

Do you have previous experience volunteering?

YES NO

If yes, where?

Do you speak any other language besides English fluently?

YES NO

If yes, what?

CURRENT EMPLOYER:
Name:
Address:
City:	State: Zip:
Phone:
CURRENT WORK SCHEDULE:


When are you available for training? Check all that apply. Weekday Evening Weekday Weekend Days Other

HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES NO *

VERIFICATION AND CONSENT FOR REFERENCE AND BACKGROUND CHECK:

I verify that the above information is accurate to the best of my knowledge.

I give the Eastern Shore Medical Reserve Corps permission to inquire into my educational background, licenses, police record, and employment and/or volunteer history. I also give permission to the holder of any such information to release it to the Eastern Shore Medical Reserve Corps.

I hold the Eastern Shore Medical Reserve Corps harmless of any liability, criminal or civil suit that may arise as a result of the release of this information about me. I also hold harmless any individual or organization that provides information to the above named agency. I understand that the Eastern Shore Medical Reserve Corps will use this information only as part of its verification of my volunteer application.


Name (please print):*	Social Security Number:*
Signature: ____________________________________	Date:

Please return this application to:

J.J. Justis, ESMRC Program Manager
P.O. Box 177,
Accomac, VA 23301

Making Our Community a Safer Place to Live!

Eastern Shore Medical Reserve Corps
P.O. Box 177
Accomac , Virginia 23301
757.787.5880, ext. 278 - phone
757.787.5841 - fax
JJ.Justis@vdh.virginia.gov