Southwest Virginia Medical Reserve Corp

Last Updated: 2-December-2008

* Denotes Required Field

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

CONTACT INFORMATION: Please include as much information as possible .

Home Phone:*		Work Phone:		Fax:
Cell Phone:		Pager Number:

Email Address:
Birthdate:
Employer:

Are you obligated to assist another health organization if an emergency were to arise? YES NO

I would like to volunteer in: (please check all that apply)

Bland	Dickenson	Norton	Tazewell
Bristol	Galax	Russell	Washington
Buchanan	Grayson	Scott	Wise
Carroll	Lee	Smyth	Wythe

Special Skills: (please check all that )

American Sign Language
Can speak languages in addition to English. List all languages below

Other skills or abilities

Medical Training and Experience (please check for all which you are certified or licensed in Virginia)

Physician	Dentist	Epidemiologist
Physician's Assistant	Registered Nurse	Licensed Practical Nurse
EMS/Paramedic	Nurse's Aide	Mental Health Professional
Pharmacist	Nurse Practitioner	Medical Receptionist/Records
Pharmacy Technician	Veterinarian	Medical or Laboratory Technician

Availability for MRC training:

Weekday Morning

Weekday Afternoon

Weekday Evening

Completion of the application does not imply in any way that the applicant has been approved as an MRC volunteer. Each applicant must receive final approval from the MRC Volunteer Coordinator. The Virginia Department of Health respects your privacy and will only use your personal information as it directly relates to the Southwest Virginia Medical Reserve Corps.

The first response to any disaster is a local response. Become a part of the response. Please consider joining the Southwest Virginia Medical Reserve Corps.

Southwest Virginia Medical Reserve Corps

15068 Lee Highway, Suite 1000 | Bristol, Virginia 24201

PHONE: 276-274-0555 | FAX: 276-645-1994

E-MAIL: swva.mrc@vdh.virginia.gov