Capital Region MRC - Volunteer Application

Sponsored by the
Capital Area Public Health Network

The Capital Region MRC Unit is supported by Concord Hospital and covers the communities of: Allenstown, Barnstead, Boscawen, Bow, Bradford, Canterbury, Chichester, Concord, Deering, Dunbarton, Epsom, Henniker, Hillsborough, Hopkinton, Loudon, Northwood, Pembroke, Pittsfield, Warner, Washington, Weare, Webster and Windsor

We appreciate your interest in the Capital Region MRC and look forward to your participation. You can complete an application online by completing and submitting the information below or you can save and print an application and mail it to Mary Reed, 103 Berry Pond Road, Pittsfield, NH 03263.

MRC Volunteer Application

A. Personal Information

Last Name First Name Middle Initial

Street Address City/Town State Zip Code

Email Address Date of Birth

Home Phone Work Phone Cell Phone Other
Please rank the order for the best way to contact you: Home Office Cell Other

Do you hold a current driver's license?

Yes No State License Number Class

B. Emergency Contact

Name Relationship

Phone Number Alternate Phone Number

C. Employment Information

Employer F/T P/T Retired Student

Check your profession/occupation/certifications:

Physician: MD	EMT: Intermediate	Dental Assistant/Hygienist
Physician: DO	EMT: Basic	Veterinarian
Physician Assistant	EMT: 1st Responder	Veterinary Technician
Nurse: RN	Mental Health Practitioner	Lab Technologist/Technician
Nurse: LPN	Social Worker	Educator (Health/Other)
Nurse: LNA	Pharmacist	Administrative Support
Nurse Practitioner	Pharmacy Technician	Disaster Preparedness
EMT: Paramedic	Dentist	Other
CPR	First Aid	Describe Other

NH Professional License: Yes No License #
Prescriptive Authority: Yes No Hospital/Healthcare System affiliation (if any)
Do you hold any other relevant license/certification e.g. Ham Radio? Yes No If yes, Title and Number

D. Other Information

Are you part of any other emergency/disaster response organization? Yes No Describe
American Red Cross Salvation Army Citizen Corps CERT Other
Do you have First Aid Certification? Yes No If yes, provide a copy of your card.
Do you have CPR Certification? Yes No If yes, provide a copy of your card.
Do you have teaching experience? Yes No Explain
Do you have HAZMAT training or certification? Yes No Training Level: Awareness OPS Tech Specialist

Do you speak any language(s) other than English? Yes No What language(s) and level of fluency?
Sign Language? Yes No

E. Anticipated MRC Involvement

What level of involvement interests you?
Tier 3 (All activities and trainings) Tier 2 (some activities and trainings) Tier 1 (Volunteer only in an emergency)
Are you interested in a leadership position with the MRC Unit? Yes No Maybe
Would you be willing to participate in a teaching/training role? Yes No Maybe
During an emergency, where would you be willing to volunteer? Locally Regionally Statewide Nationally

All information is confidential and is for the use of the Capital Region Medical Reserve Corps. However, in certain circumstances it may be necessary to share this information with emergency management and Health and Human Service agencies.

I give my permission for the MRC to release personal information to local, state and federal emergency management agencies and other Health and Human Service agencies, as needed. All of the information I have supplied is correct to the best of my knowledge. I do hereby give my local Medical Reserve Corps (MRC) permission to make inquiries concerning licensure and certification. I understand that I am a volunteer and will not be paid for any of my services.

I am willing to submit to a background check as may be required by the State of New Hampshire.

Signature Acknowledgement

Date

Medical Professionals - After you submit your MRC application, you may want to go to www.iCanHelp.NH.gov and register for NH’s Emergency System for Advance Registration of Volunteer Healthcare Professionals (ESAR-VHP) so that your credentials can be verified. If you don't do this now, we'll work with you during orientation to get you registered.

Sponsored by the Capital Area Public Health Network

We appreciate your interest in the Capital Region MRC and look forward to your participation. You can complete an application online by completing and submitting the information below or you can save and print an application and mail it to Mary Reed, 103 Berry Pond Road, Pittsfield, NH 03263.

MRC Volunteer Application

A. Personal Information

Last Name First Name Middle Initial

Street Address City/Town State Zip Code

Email Address Date of Birth

Home Phone Work Phone Cell Phone Other Please rank the order for the best way to contact you: Home Office Cell Other

Do you hold a current driver's license?

Yes No State License Number Class

B. Emergency Contact

Name Relationship

Phone Number Alternate Phone Number

C. Employment Information

Employer F/T P/T Retired Student

Check your profession/occupation/certifications:

NH Professional License: Yes No License # Prescriptive Authority: Yes No Hospital/Healthcare System affiliation (if any) Do you hold any other relevant license/certification e.g. Ham Radio? Yes No If yes, Title and Number

D. Other Information

E. Anticipated MRC Involvement

All information is confidential and is for the use of the Capital Region Medical Reserve Corps. However, in certain circumstances it may be necessary to share this information with emergency management and Health and Human Service agencies.

I am willing to submit to a background check as may be required by the State of New Hampshire.

Before submitting your completed form, you may want to print your submission

Sponsored by the
Capital Area Public Health Network

Home Phone Work Phone Cell Phone Other
Please rank the order for the best way to contact you: Home Office Cell Other

NH Professional License: Yes No License #
Prescriptive Authority: Yes No Hospital/Healthcare System affiliation (if any)
Do you hold any other relevant license/certification e.g. Ham Radio? Yes No If yes, Title and Number