MRC Registration

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* 1. Full Name

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* 2. Mailing Address Street

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* 3. Mailing Address Town

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* 4. Mailing Address State

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* 5. Mailing Address Zip Code

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* 6. Home Phone

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* 7. Work Phone

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* 8. Cell/mobile phone

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* 9. Cell/mobile phone carrier (ie verizon, sprint, google fi)

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* 10. Fax

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* 11. Email (Primary)

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* 12. Email (Secondary)

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* 13. Date of birth

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* 14. Have you ever been convicted of a felony

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* 15. Are you willing to submit to a background check?

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* 16. Do you have a current driver's license

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* 17. If yes

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* 18. What is the best way to contact you in an emergency?  Please rank

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* 19. Are you fluent in any languages other than English?

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* 20. Do you know sign language?

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* 21. Would you be willing to work as interpreter in an emergency

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* 22. Medical Professionals: Indicate your profession

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* 23. Are you currently CT licensed in your profession?

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* 24. If a physician, are you board certified?

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* 25. If a nurse, do you have prescriptive authority?

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* 26. Non-Medical Volunteers:

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* 27. Are you CPR/AED certified

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* 28. Are you First Aid certified

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* 29. What is your current employment status?

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* 30. Please confirm the information is true and accurate.

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.  

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