Membership Application

Open Application File

      -OR-

Copy & Paste both pages below and email to us at efernandes@cheshire-med.com

  or mail to us at: 

Greater Monadnock Medical Reserve Corps, c/o GMMRC
Housing Unit: 580 Court Street Keene, NH 034341
          

Greater Monadnock

Medical Reserve Corps

Fiscal Agent: County of Cheshire 33 West Street Keene, NH 03431

Housing Unit: 580 Court Street Keene, NH 034341

Telephone:  (603) 354-5454 x2130      Facsimile:  (603) 354-6674

Website: http://gmmrc.org

E-mail: efernandes@cheshire-med.com

VOLUNTEER APPLICATION    Date: _____________

Personal Information

 

Name:

            Last                                                              First                                                                                      MI

 

Mailing Address:

                              

                  Street                            Apt/Ste           PO Box                         City                                                 State               Zip Code

 

Telephone:

Home:

Work:

Cell:

Pager/Other

 

E-mail (if available):Primary:

                                                        Secondary:

 

Date of Birth:

                                              mm/dd/yyyy

 

Emergency

Contact:      Name                                  Relationship

 

Phone

Alt. Phone

 

Do you hold a current NH driver’s license?  □ Y □ N  NH DL#

Professional Information              ALL INTERESTED VOLUNTEERS ARE WELCOME!

                                                          Subject to background check

Check your profession/occupation (check only one):

 

*If retired, check profession prior to retiring

Physician   __MD  __DO                                                           □  Physician’s Assistant

Nurse Practitioner                                                                     □  Nurse

Pharmacist                                                                                   Dentist

Veterinarian                                                                                Mental Health Professional

EMS Professional                                                                       Respiratory Therapist

Other Public Health/Medical                                                    Non-Public Health/Non-Medical                               

Please complete both sides of application

Helpful Information (optional)

Are you part of any other emergency/disaster response/alert system?  □  Y     □  N

  □ American Red Cross         □ Salvation Army              □ Citizen Corps CERT                   □ NSP

Do you speak a foreign language?  □  Y     □  N            Sign Language?  □  Y     □  N

Please list:

Language

Fluent

Well

Fair

Slight

Teaching Experience?      □  Y     □  N

Leadership Experience?        □  Y   □  N

I prefer to:

Prepare for service in a Greater  Monadnock Region emergency/disaster only                                  

Prepare for service in a State of NH emergency/disaster                                                                      

Prepare for service in a New England and beyond emergency/disaster                                               

Participate in community health initiatives                                                                                            

Participate in a leadership role                                                                                                                 

Participate in a teaching/training role                                                                                                     

Do you have family obligations to consider before responding to an emergency?   □  Y     □  N

Do you have any special skills or knowledge that would help our unit?

Thank You!

All information is held confidential and is for the strict use of the Greater Monadnock Reserve Corps.  It will not be shared with any other organization, for any reason, without the expressed written consent of the individual applicant.  In compliance with the Privacy Act of 1974.

Please complete both sides of application.

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