Miami-Dade Medical Reserve Corps Orientation Seat Reservation Thursday, October 22, 2015

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Email Address

Question Title

* 4. Phone Number

Question Title

* 5. Are you currently employed?

Yes

No

If yes, please specify current employer

Question Title

* 6. Are you certified or licensed in any health field?

M.D/D.O

D.V.M/V.M.D

R.N.

L.P.N.

EMT/Paramedic

Counselor

P.A/N.P

Pharmacist

Psychiatrist/Psychologist

Microbiologist

Foreign Medical Doctor

Other (please specify)

Question Title

* 7. Are you currently CPR certified?

Yes

No

If no, is this something you would be interested in?

Question Title

* 8. Please list any experience you have in an emergency response?