Peninsula Medical Reserve Corps

Peninsula Health District, Hampton Health District &
Three Rivers Health District

Preliminary VOLUNTEER Application

If you would like to apply to become a MRC volunteer please complete the form below online or click here to print the PDF of the volunteer application. You can return your printed application via mail or fax.

* Denotes Required Field

*First Name:

*Last Name:

*Mailing Address:

*City:

State:

Home Email:

Work
Email

*Home Phone:

*Cell Phone:

Employer:

Job Title:

Employment Status

Full-time

Part-time

Retired

Unemployed

I am willing to volunteer in the PENINSULA Medical Reserve Corps in the following cities/counties:

Hampton	Newport News	York County	James City County	Williamsburg
Poquoson	Three Rivers Health District	(Essex, Gloucester, King & Queen, King William, Lancaster, Mathews, Middlesex, Northumberland, Richmond, & Westmoreland counties)

Please mark the following positions that you have the skills and certifications to perform:

Physician Speciality	Dentist/Hygienist	Telecommunication/IT Support
Physician Assistant	Registered Nurse	Admin/Logistics/Coordination
EMT/Paramedic	Veterinarian	Mental Health Professional
Pharmacist	Nurse Practitioner	Teacher/Educator/Interpreter
Pharmacy Technician	Other:	Medical or Laboratory Technician

Your professional license is:

Active
Inactive
N/A

Your CPR license is:

Current
Expired
N/A

Please list any training, certifications or qualifications that you have that could be an asset to the MRC unit.

NOTE: Upon acceptance you will be asked to provide a copy of all licenses and additional volunteer information. Some volunteer positions may require background checks. The Virginia Department of Health respects your privacy and will only use your personal information as it directly relates the PENINSULA MRC.

Please return this form to the PENINSULA Medical Reserve Corps Unit at: 416 J. Clyde Morris Blvd, Newport News, VA 23601 or fax to (757) 594-7714. For more information call Jennifer Freeland, MRC Coordinator at (757) 594-8045 E-mail jennifer.freeland@vdh.virginia.gov or visit www.vdh.virginia.gov/MRC.

5,000 MRC volunteers
areneeded to serve
the public health needs
of our communities.

We Need YOU!

Join the
PENINSULA MRC
Today!

PENINSULA Medical Reserve Corps
416 J. Clyde Morris Blvd.
Newport News, Virginia 23601
Phone: (757) 594-8045
Fax: (757) 594-7714
peninsulamrc@vdh.virginia.gov