Cook County MRC Volunteer Application

Cook County Medical Reserve Corps Volunteer Application

Please complete the form below to apply as a volunteer with CCMRC.
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Phone Number*

Area CodePhone Number
Phone Type*
YesNo
State Driver's License Held
Driver's License Number
Healthcare ProfessionalNon-Medical
Type of Non-Medical Volunteer:
Healthcare Professional Information
Type of Healthcare Professional
If other, please define below
If Other than listed above:
Copy of Medical License

Upload a File
This is needed for credentialing purposes Cancelof
Medical License Number
State License Held

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*

MonthDayYear
Date
Other Names (including maiden)
YesNo
If yes, please explain
YesNo
If yes, please explain

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.
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Cook County Medical Reserve Corps Volunteer Application