FL MRC Basic Volunteer Contact Form

 
FL MRC Website: www.floridamrc.com
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1. Select one of the FL MRC Units below that you would like to join or become a member:
Contact Information:
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2. First Name:
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3. Middle Name:
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4. Last Name:
5. Suffix:
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6. Work Location: Example - Hospital Name, Clinic Name, Florida Department of Health
7. Work Street Address: Line 1
8. Work Street Address: Line 2
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9. Work City:
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10. Work County:
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11. Work Zip:
12. Home Street Address: Line 1
13. Home Street Address: Line 2
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14. Home City:
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15. Home County:
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16. Home Zip:
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Please enter at least one contact method in this section in order for a MRC Coordinator to contact you directly to begin the FL MRC Volunteer process of becoming a member of the FL MRC Network.
17. Work Phone Number:
18. Work Phone Number Extension:
19. Work Cell Phone Number:
20. Personal Cell Phone Number:
21. Home Phone Number:
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22. Work Email Address:
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23. Personal Email Address:
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FL MQA Website Link: https://ww2.doh.state.fl.us/IRM00PRAES/PRASLIST.ASP
(copy and paste the URL into your browser's address bar)
24. Professional Background & Current Occupation (1): Primary
List of License Prefixes: List of license prefixes the Division of Medical Quality Assurance uses for the professions it regulates and what profession the prefix identifies:
25. License Prefix: Example: EMT, RN, CNA
26. License Number:
27. Occupation Professional Status:
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FL MQA Website Link: https://ww2.doh.state.fl.us/IRM00PRAES/PRASLIST.ASP
28. Professional Background & Current Occupation (2): Secondary
List of License Prefixes: List of license prefixes the Division of Medical Quality Assurance uses for the professions it regulates and what profession the prefix identifies:
29. License Prefix: Example: EMT, RN, CNA
30. License Number:
31. Occupation Professional Status:
Please feel free to contact me if you have any questions or need assistance with completing this form. Once you have submitted your FL MRC Basic Contact Form, you will be contacted by your Local MRC Coordinator.
Rick Miller
FL MRC Program Manager
Bureau of Preparedness and Response
Division of Emergency Preparedness and Community Support
Florida Department of Health
Office Phone Number: 850.245.4444 ext. 3876
Email: Rick.Miller@flhealth.gov

Mission of the Department of Health:
To protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.

Vision statement: Healthiest State in the Nation

Values: (ICARE)
Innovation: We search for creative solutions and manage resources wisely.
Collaboration: We use teamwork to achieve common goals & solve problems.
Accountability: We perform with integrity & respect.
Responsiveness: We achieve our mission by serving our customers & engaging our partners.
Excellence: We promote quality outcomes through learning & continuous performance improvement.

PLEASE NOTE: Florida has a very broad public records law. Most written communications to or from state officials regarding state business are public records available to the public and media upon request. Your email communications may therefore be subject to disclosure
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