Santa Cruz County Medical Reserve Corps Sign Up Form

Santa Cruz County Medical Reserve Corps

  1. 2150 N. Congress Dr., Suite 204, Nogales, AZ 85621

    Office: 520-375-7900     

    Fax: 520-375-7428

  2. Please complete the information below. * Indicates required information

  3. 1. Personal Information

  4. 2. Professional and Employment Information

  5. Current Employment*
  6. 3. Other Response Obligations

  7. CPR: 

  8. 4. Training, Skills, and Education

  9. (i.e. computer/IT, logistics, disaster response experience, education, etc.):

  10. 5. Your Interests

  11. 6. Data Security, Privacy, and Consent

  12. All information is confidential and is for the use of the BC-MRC and Bucks County Department of Health. However, in certain circumstances it may be necessary to share this information with Emergency Management and Health and Human Service agencies. I give my permission for the BC-MRC to release my information to local, state, and federal emergency management agencies and other Health and Human Service agencies as needed.*

    (I understand this may prevent me from volunteering with the BC-MRC)

  13. I verify that the above information is accurate to the best of my knowledge. I do hereby give my local Medical Reserve Corps (BC-MRC) permission to make inquiries concerning licensure, certification, and criminal history.

    (I understand this may prevent me from volunteering with the BC-MRC)

  14. (typing your name is considered the same as your signature)

  15. Leave This Blank:

  16. This field is not part of the form submission.