Medical Reserve Corps Registration MRC Registration Question Title * 1. Full Name OK Question Title * 2. Mailing Address Street OK Question Title * 3. Mailing Address Town OK Question Title * 4. Mailing Address State OK Question Title * 5. Mailing Address Zip Code OK Question Title * 6. Home Phone OK Question Title * 7. Work Phone OK Question Title * 8. Cell/mobile phone OK Question Title * 9. Cell/mobile phone carrier (ie verizon, sprint, google fi) OK Question Title * 10. Fax OK Question Title * 11. Email (Primary) OK Question Title * 12. Email (Secondary) OK Question Title * 13. Date of birth OK Question Title * 14. Have you ever been convicted of a felony Yes No OK Question Title * 15. Are you willing to submit to a background check? Yes No OK Question Title * 16. Do you have a current driver's license Yes No OK Question Title * 17. If yes License # State OK Question Title * 18. What is the best way to contact you in an emergency? Please rank 1 2 3 4 5 Home phone 1 2 3 4 5 E-Mail 1 2 3 4 5 Cell phone 1 2 3 4 5 Work phone 1 2 3 4 5 Fax OK Question Title * 19. Are you fluent in any languages other than English? Yes No If yes, please list the language(s) OK Question Title * 20. Do you know sign language? Yes No OK Question Title * 21. Would you be willing to work as interpreter in an emergency Yes No OK Question Title * 22. Medical Professionals: Indicate your profession M.D. P.A. A.P.R.N. R.N. L.P.N. Paramedic EMT Dentistry Pharmacist Veterinarian Other Specialty OK Question Title * 23. Are you currently CT licensed in your profession? Yes No If yes, license # OK Question Title * 24. If a physician, are you board certified? Yes No Certification speicalty: OK Question Title * 25. If a nurse, do you have prescriptive authority? Yes No If yes, authorization # OK Question Title * 26. Non-Medical Volunteers: Please indicate your occupation Please list any special skills (computer skills, people skills, leadership experience, teaching experience, organizational skills, etc.) OK Question Title * 27. Are you CPR/AED certified Yes No If yes, expiration date: OK Question Title * 28. Are you First Aid certified Yes No If yes, expiration date: OK Question Title * 29. What is your current employment status? Full-time Part-time Student Retired Other OK Question Title * 30. Please confirm the information is true and accurate. "I affirm the information provided is true and accurate." OK Thank you for volunteering.. You will be contacted by Cecile Serazo to schedule orientation. Any questions can be directed to her at 860-429-3325. OK DONE