Michigan Medical Reserve Corps

Ingham County Medical Reserve Corps Application

First Name
Last Name
Primary Address
City
State
Zip
Email Address
Primary Telephone
Secondary Telephone
Comments
How did you hear about volunteering for Medical Reserve Corps?
Have you previously volunteered through RSVP, Red Cross or another organization?	Yes No
If yes, where?
Previous Experience in Medical Settings
Organization #1
Title/Position
Job Duties
Organization #2
Title/Position
Job Duties
Organization #3
Position/Title
Job Duties
Education/Credentials
Highest Level of Education Completed
Please specify a major
Medical Education: Medical specialty degree (name or type of degree) was obtained from (institution) on (date).
Other Skills/Credentials
Are you fluent in a second language? If so, please list:
What types of assignments would you like? (Check all that apply)
Type of Assignment:	Full Year Spring Summer Fall Winter
Type of Setting:	Clinics or Health Fairs Training Sites Disaster Drills Trained Volunteer to Serve at Emergencies/Disasters Special Projects Assisting the Public Health Department
Personal Information
Date of Birth
Sex	Male Female
Ethnic/Racial Origin (optional)	Caucasian/White African American/Black Asian/Pacific Islander American Indian/Eskimo/Aleut Other
Are you Hispanic?	Yes No
Are you Multiracial? If yes, please check all that apply.	Caucasian/White African American/Black Asian/Pacific Islander American Indian/Eskimo/Aleut Other
Marital Status
Currently my health is...
Activity restrictions? Please list.
Disabilities? Please list.
Do you have a health, physical, or dietetic factor that could affect a volunteer placement? If yes, please explain:
Are you responsible for the care of underage children?	Yes No
If yes, would you need care for your children when you serve through the Ingham County Medical Reserve Corps?
Are you the primary caregiver for a dependent adult?	Yes No
If yes, would you need care for your loved one should you be called to serve?
In case of emergency please notify:
Name
Phone
In the event of a medical emergency, I authorize emergency medical treatment.	Yes No
Preferred hospital
SVP provides personal liability, excess auto liability, and personal accident insurance coverage for all RSVP volunteers while they are volunteering. To place the insurance in effect we must have a statement of beneficiary from you. My beneficiary for RSVP insurance is:
Name
Relationship
Address
City
State
Zip
Phone
References (Someone unrelated to you who you have known for at least two (2) years)
Reference #1: Name
Phone
City
State
Zip
Reference #2: Name
Phone
City
State
Zip
Authorization
I authorize the Ingham County Medical Reserve Corps to use my photograph for public relations purposes.	Yes No

Thank you for your participation.