MCDH Prepare!

McHenry County Department of Health

Emergency Response Program

Working to protect the health and safety of McHenry County Residents
by planning for and responding to public health emergencies

Medical Reserve Corps Application

First Name	Middle Name	Last Name


Salutation	Maiden Name	Gender
		Male Female

Home Address:


City:	State	Zipcode:


Home Email Address:	Work Email Address:


Home Phone:	Work Phone:	Cell Phone:


Pager:	Fax:


Social Security Number:	Driver's License Number:	Driver's License State:


Date of Birth	Race




Preferred Method of contact (Check Boxes)
Home Phone	Work Phone	Cell Phone
Pager	Home Email	Work Email



Emergency Contact
Name	Phone Number




Medical History (Check Boxes)
Epilepsy	Diabetes	Cardiac Disease
Auto-Immune Disease	Cerebral Palsy	Vascular Disorder
Parkinson's Disease	Multiple Sclerosis	Hemophilia
Hearing Disorder	Eye Disorder	Behavioral Health
Back Trouble	Other Explain

If you checked any of the above, please explain your limitations to ensure proper placement




Profession
Profession	Are you actively practicing?	License Number
	Yes No

State	Expiration




Employment
Presently not Working	Hospital	Clinics
Public Health	EMS	Retired
Private Practice	Other

Present Employer	Supervisor	Phone Number


Street Address	City	State


Zipcode	Position / Title




Travel
Would you be willing to travel?	How Far?	What Length of Time?
Yes No



Student Information (if applicable)
Institution	Area of Study or Major	Expected Date of Completion




Area of Expertise
Languages in which you are fluent





Please Check if you have certification or training in any of the following
	Month / Year
CPR	/
First Responder Training	/
First Aid	/
CERT Training	/
INVENT Training	/
ALS Training	/
Haz Mat Training	/
Emergency Medical Training	/
Infection Control	/
Incident Management	/
Risk Communication	/
Bloodborne Pathogens	/
Other	/



References
Name # 1	Phone Number	Email Address

Street Address	City	State

Zip code


Name # 1	Phone Number	Email Address

Street Address	City	State

Zip code




How did you learn about the Medical Reserve Corps of McHenry County?


What interested you in becoming a member of the McHenry County Medical Reserve Corps?




Authorization
I Certify that the answers given herein are true and complete. I authorize investigation of all statements contained in this application for volunteer placement as may be necessary in arriving at a placement decision. McHenry County Department of Health has my permission to contact the above references. I understand that by signing below, I also give permission for McHenry County Department of Health to conduct a criminal background check. I understand that my name and contact information will be put into a database to be managed by the McHenry County Department of Health.
By entering your email address you are signing your name to the above
Date

Information About

McHenry County Online ~ MCDH Online

McHenry County Department of Health
2200 N Seminary Ave, Annex A
Woodstock, Illinois 60098

Telephone (815) 334-4510

Fax (815) 338-7661