Cook County Medical Reserve Corps Volunteer Application
Please complete the form below to apply as a volunteer with CCMRC.
Full Name
*
First Name
Middle Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email Address
*
Phone Number
*
-
Area Code
Phone Number
Phone Type
*
Home
Mobile
Do you have a valid Driver's License?
*
Yes
No
State Driver's License Held
Driver's License Number
Type of Volunteer
*
Healthcare Professional
Non-Medical
Type of Non-Medical Volunteer:
Healthcare Professional Information
Type of Healthcare Professional
Please Select
Doctor (all categories)
Nurse
Pharmacy
Other
If other, please define below
If Other than listed above:
Copy of Medical License
This is needed for credentialing purposes
Medical License Number
State License Held
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Volunteer Participation
All level of volunteer will need to attend (either online or in-person) some basic training and/or MRC orientation from the Cook County Department of Public Health Emergency Preparedness and Response Unit
Level of Participation Desired
*
Active (receives notifications of all trainings, drills, exercises, emergency events, and non-emergency volunteer opportunities)
Limited (receives only notification of drills, exercises and emergency events)
Emergency Only (receives only notification of major emergency events)
Which community would you prefer to serve in?
*
Northern Cook County
Western Cook County
Southern Cook County
All of the above
Would you deploy outside of Cook County?
*
Yes
No
Do you volunteer with any other MRC Unit in Illinois?
Yes
No
If so, which one?
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Interests
Please rate your MRC interests from 1 to 4. 1 is least desired and 4 is most desired.
Emergency response, medical support, general support (first aid, vaccinations, triage, etc.)
1
2
3
4
Public health information, education/community outreach (health fair, community fair)
1
2
3
4
Program Lead (volunteer training and management)
1
2
3
4
Assist in Mass Care (sheltering, logistics)
1
2
3
4
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Additional Certifications
Please indicate any additional current certifications that you have
CPR
Adult
Child
Infant
First Aid
Yes
No
FEMA Independent Study Courses
IS 100
IS 700
IS 200
IS 800
CERT (Community Emergency Response Team)
Yes
No
Bloodborne Pathogens
Yes
No
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Office or Medical Skills
Do you have experience entering data into a computer database?
Little
Moderate
Proficient
Do you have access to the internet at home?
Yes
No
Are you able to email from home?
Yes
No
Do you or have you supervised staff or volunteers?
Yes
No
Have you been trained to give injections?
Yes
No
Please specify if you have experience giving the following injections
Intramuscular
Subcutaneous
Intradermal
Adult
Infant
Children
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Criminal Background Check
A criminal background check is required of all volunteers. No sex offense convictions; no drug convictions. Past convictions will not necessarily prevent a volunteer from being accepted, but will be evaluated on a case by case basis.
Birthdate
*
-
Month
-
Day
Year
Date
Other Names (including maiden)
Have you every been convicted of a felony?
*
Yes
No
If yes, please explain
Have you ever been convicted of a misdemeanor?
*
Yes
No
If yes, please explain
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Privacy Act Statement
This information is requested by the Cook County Medical Reserve Corps for the purpose of organizing volunteers and staff to respond to area emergencies, disasters or public health emergencies. It will not be utilized or released for any other purpose without your express written permission unless required by law.
Submit Volunteer Application
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