MRC-CERT Salem County Application for Medical Reserve Corps and/or Community Emergency Response Team If you are human, leave this field blank.Personal InformationFull Name *Application Date (mm/dd/yy) Email *Date of Birth (mm/dd/yy)Drivers License Number, Class and StateLicense Expiration (mm/yy)Complete Address (Street, City, State, Zip)Home Phone Number Cell Phone NumberOther PhoneWhich number do you prefer to be contacted on? Home PhoneCell PhoneOther PhoneEmployment InformationMost Recent / Current Employer: Employer Address (Street, City, State, Zip)Emergency ContactFull NameRelationshipEmergency Contact Address (Street, City, State, Zip)Home Phone Number Cell Phone Number AvailabilityInstructionsPlease indicate the days and times you are usually available to volunteer. This would be for routine volunteer opportunities. Everyone will receive a call for emergency activations and response would always depend on your personal availability. SundayMorningAfternoonEveningMondayMorningAfternoonEveningTuesdayMorningAfternoonEveningWednesdayMorningAfternoonEveningThursdayMorningAfternoonEveningFridayMorningAfternoonEveningSaturdayMorningAfternoonEveningQuestionsAre you willing to travel and volunteer outside your county? YesNoCommentsAre you willing to participate in a Federally coordinated emergency response? YesNoCommentsAre you willing to provide translation services?YesNoCommentsDo you have the ability to communicate using sign language?YesNoCommentsHave you been immunized against smallpox? YesNoCommentsDo you have any special needs or restrictions? If so, please explain. YesNoCommentsAre you committed to any other organization by employment or volunteerism in the event of a public health emergency? If so, please explain. YesNoCommentsDo you have a particular expertise and agree to be available for consultation or response throughout the state? YesNoCommentsProfessional Licensure, Certifications, Specialities, ExperienceName of License/Certification: License/Certification Number:State of License/Certification: License Type:Status (Active, Expired etc) : Specialty within the above professional license/certification that you possess: Sub specialty within the above professional license/certification that you possess: Expectations of MRC and CERT Volunteers (both must be selected)Salem County MRC-CERT is open to all Salem County Residents over 18 years old. We do not discriminate and the MRC-CERT program has something that everyone can participate in regardless of physically abilities.MRC Volunteers:I agree to the below statement (failure to agree invalidates this application)As a volunteer within the New Jersey Medical Reserve Corps, I will be called upon to assist in the event of a public health emergency. I agree to attend an educational program to explain my role in disaster preparedness; I will be assigned duties based on my level of training and education and experience. I understand that submitting this application does not guarantee acceptance into the NJ Medical Reserve Corps. The information contained in this application is, to the best of my knowledge, truthful. I agree to serve my fellow citizens to the best of my ability.CERT Volunteers:I agree to the below statement (failure to agree invalidates this application)My submission of this application attests that I am at least 17 years of age. Applicants 17 years of age may participate in the training but will not be eligible for actual emergency deployment until they turn 18. CERT training is open to all Salem County residents. Admission to the Salem County Team after completion of the training is subject to approval of the Team Management upon submission of all appropriate documentation. I also understand that my application and completion of the training class does not require me to join the Salem County Team.Captcha *reCAPTCHA is required.Submit
Salem County Application for Medical Reserve Corps and/or Community Emergency Response Team
Salem County Application for Medical Reserve Corps and/or Community Emergency Response Team 
