LaSalle County Medical Reserve Corps Volunteer Application

LaSalle County Medical Reserve Corps Volunteer Application
NAME*

First NameMiddle NameLast Name
OTHER NAMES USED (including maiden name)*
BIRTHDATE*

MonthDayYear
EMAIL*
example@example.com
PHONE NUMBER
Please enter a valid phone number.
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DRIVER'S LICENSE OR STATE ID #*

NUMBERSTATE ISSUEDEXPIRATION DATE
EMPLOYER
TYPE: HEALTHCARE PROFESSIONAL*
OTHER HEALTHCARE PROFESSIONAL (please specify)
HEALTHCARE PROFESSIONAL LICENSE/CERTIFICATION NUMBER
STATE ISSUED
LICENSE/CERTIFICATION EXPRIATION DATE
TYPE: NON-MEDICAL (enter Job Title)
SECOND LANGUAGE
I PREFER TO BE:*

ACTIVE: receive notifications of ALL training opportunities, drills and exercises, emergency events, and non-emergency volunteer opportunitiesLIMITED: receive only notification of training drills and exercises, and all emergency eventsEMERGENCY ONLY: receive notification of ONLY major emergency events
WHICH COMMUNTY WOULD YOU PREFER TO SERVE IN?*

ANY COMMUNITY WITHIN LASALLE COUNTYLaSalle/PeruOttawaMendotaStreatorLake HolidayOglesbyI AGREE TO BE DEPLOYED OUTSIDE OF THE AREA
A Criminal Background Check is required of all volunteers. No sex offense convictions; no drug convictions within last ten (10) years. Past convictions will not necessarily prevent a volunteer from being accepted but will be evaluated on case by case basis.
HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR (other than a traffic violation)?*

YESNO
HAVE YOU EVER BEEN CONVICTED OF A FELONY?*

YESNO
IF YES TO EITHER QUESTION ABOVE, PLEASE EXPLAIN
Signature*

Clear
Should be Empty: