DeKalb Public Health Emergency Preparedness Volunteer Information Form

DeKalb Public Health Emergency Preparedness Volunteer Information Form

Please answer all questions.
Personal Contact Information
Today's Date

MonthDayYear
Date
Title (check one)

Dr.Mrs.Mr.Ms.
Full Name*

First NameLast Name
Maiden name or other name used
How did you hear about the Medical Reserve Corps (MRC)?
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Home Fax #

Area CodePhone Number
Email Address*
example@example.com
**Please indicate the BEST number to contact you for activation:*

Area CodePhone Number

Emergency Contact Information

Please provide a contact name who can be reached if you are injured, etc.
Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Phone #*

Area CodePhone Number
Additional Emergency Contact Information
In the event that you are activated to respond to an emergency: Please list additional person(s) who may be used to contact you if we are unable to reach you using the information provided above.
Contact Name

First NameLast Name
Phone #

Area CodePhone Number
Additional Phone #

Area CodePhone Number
Additional Contact Information

Deployment Preferences

Please indicate your preferences by checking all that apply
During an emergency where are you willing to serve?*

In county onlyOnly to neighboring countiesOut of county (in state only)Out of state (USA only)
What is the maximum number of days that you can be away?

Personal Contact Information