Boston Medical Reserve Corps Application

Please note: All fields marked with a red star (*) are required.

1. Personal Information:
*First Name         *Last Name  Title
2. Contact Information:
Mailing Address
*Mailing Address (line 1)   Mailing Address (line 2)   Apt No.
*City   *State *Zip Code
 
Home Address: (if different from above)
Home Address (line 1)          Home Address (line 2) Apt No.
City  State Zip Code
Email & Phone:
*Email Address Email Address (Alternate)
*Daytime Phone Ext *Evening Phone Mobile Phone Pager (+extension if applicable)
3. Emergency Contact Information:
*Emergency Contact  *Relationship *Emerg. Contact Phone Emerg. Contact Email
* For Volunteers with Clinical Training / Licensure *
Please review and complete the following sections indicating appropriate title and/or occupation listed.
* All other Volunteers may skip to Section 5 - Skills / Areas of Expertise. *
4. Occupation / Background (Please check all that apply)
Counseling / Mental Health Nurse Practitioner
Dentist Pharmacist
Dental Assistant Pharmacy Technician
Dental Hygienist Physician
EMT / Paramedic Physician Assistant
Epidemiology Public Health
Epidemiology (Nurse) Toxicologist
Lab Technician Veterinarian
Nurse Vet Tech 
Nurse (Clinical Specialist)  

Student (please specify school, program of study and graduation date)

Other (please specify)
Please indicate any applicable clinical degrees (i.e. MD, RN)

Are you currently licensed to practice in Massachusetts?
Yes (License # )
No  
N/A
If Yes, License Expiration Date

Please indicate any affiliations with health care organization (hospital, health center, visiting nurse assoc.)
5. Skills / Areas of Expertise (check all that apply)
Case Management (Non-Clinical) Inspection
Clinical / Nursing Case Management Interviewing
Communications Logistics
Communicable Disease Materials Management
Community Organizing Maternal / Child Health
Counseling Media / Public Relations
Crisis Intervention

Mental / Behavioral Health
Customer Service Outbreak Investigation
Data Analysis Patient Advocacy
Data Entry Phlebotomy
Events Organizer Provider Education
Hazardous Materials School Health
Health Education Triage
Home Visiting Vaccination

Other (please specify)

6. Language (Please select level of proficiency in any of the following languages.)
Language Speaking Reading Writing Medical
Interpretation
 Cape Verdian
 Cantonese
 Chinese
 French
 French Creole
 Hatian Creole
 Khmer
 Mandarin
 Polish
 Portuguese
 Russian
 Spanish
 Vietnamese

 Other (specify)
 

7. Level of Boston MRC Involvement. Please indicate the level you are interested in: (Please check only one)
Response Level. The response level involves a minimal time commitment. Members are activated only in the event of a public health emergency. The only pre-event training requirement is a 1.5 hour orientation. If activated, you will receive event specific training before you are deployed.
Leadership Level. Becoming a leadership level volunteer requires a larger initial commitment, including and additional 8-10 hours of training. In addition, a refresher course is required once a year. As with response level, members are only activated during a public health emergency and will be given "just-in-time" training specific to the event.

8. How did you hear about Boston MRC?

Brochure
Friend or colleague
Website (please specify)
Professional organization (list here)
Internet Ad (which website?)
Subway Ad (what location / line?)
Bus Ad (what location / line?)
Newspaper Ad (which newspaper?)
Mailing
Other (list here)

Criminal Offense Records Investigation (CORI)


*Today's Date (MM/DD/YYYY)

             
*Last Name                                         *First Name                                               Middle Name

            
Married/Maiden name if                       *Date of Birth (MM/DD/YYYY) 
different from above

*By putting your initials in this box I certify that the above information is correct and I allow the Boston MRC and the Boston Public Health Commission to perform a criminal background check as part of my application to become a Boston MRC volunteer.
               (If the CORI section of this form is not filled out entirely you will not be able to become a volunteer)