Emergency Contact Information In case of emergency, please contact: Relationship: Daytime Phone: Evening Phone Do you have any personal health issues that would impact If yes, please list here: your ability to volunteer? □ Yes No Personal References: Please list 3 personal/professional references Education Highest Level of Education: Year Graduated: □ □ □ High School College Graduate School Other Name of Graduating School: Degree: Major: Are you part of an emergency/disaster If yes, please explain: plan with any other organization? □ Yes No How did you learn about the Medical Reserve Corps? Cowley I hereby certify that all information on this application is accurate and correct and I hereby make application to the County Medical Reserve Corps. I understand that I am applying for a volunteer position and this is not an application for, nor a contract of, employment. I understand that this application does not automatically make me a credentialed volunteer and that further interviews and training will take place. I understand that every attempt will be made to reduce the risks to volunteers; however, some risks may be present during a public health emergency or disaster. I further understand and give written permission for the Cowley County Medical Reserve Corps to submit my name for criminal and driving background checks. Also, I realize that my professional licensure status will be verified. Signature of Applicant Date
Emergency Contact Information In case of emergency, please contact: Relationship: Daytime Phone: Evening Phone Do you have any personal health issues that would impact your ability to volunteer? Yes □ No If yes, please list here: Personal References: Please list 3 personal/professional references Education Highest Level of Education: High School □ College □ Graduate School □ Other Year Graduated: Name of Graduating School: Degree: Major: Are you part of an emergency/disaster plan with any other organization? Yes □ No If yes, please explain: How did you learn about the Medical Reserve Corps? I hereby certify that all information on this application is accurate and correct and I hereby make application to the Cowley County Medical Reserve Corps. I understand that I am applying for a volunteer position and this is not an application for, nor a contract of, employment. I understand that this application does not automatically make me a credentialed volunteer and that further interviews and training will take place. I understand that every attempt will be made to reduce the risks to volunteers; however, some risks may be present during a public health emergency or disaster. I further understand and give written permission for the Cowley County Medical Reserve Corps to submit my name for criminal and driving background checks. Also, I realize that my professional licensure status will be verified. Signature of Applicant Date
volunteer_applicationWORD.docx