Thursday, May 17, 2012
 
MRC Training & Registration

Be Food Safe!

Food handling safety risks at home are more common than most people think.  The four easy lessons of Clean, Separate, Cook and Chill can help prevent harmful bacteria from making your family sick.  To find out more about food safety, visit befoodsafe.gov.

Does your kitchen make the grade?  Read More

Step 1 - Registration (Continued)

Mahoning/Columbiana Medical Reserve Corps

Volunteer Application.

Personal Information

Name




   

Home Address






Work Address





Contact Information






Emergency Contact Information - To be notified in case of an emergency








Do you have any personal health issues that would
impact your ability to volunteer? (For example
allergies, medication issues, disabilities, special
needs, or being treated for a medical condition). If
Yes, you will be asked to provide an explanation.

License, Permissions and Checks

Professionals with a current license or certification in any health or mental health field

Are you an Ohio licensed professional? If yes, you
will be asked to fill out details regarding your Medical
Profession, Medical Specialty, Medical License
Number and License Expiration Date. This section is
required for liability protection as a Medical Reserve
Corps volunteer:

Photo Permission

By checking the box below I am giving my
permission to be photographed for publicity purposes.
I understand that this information may appear publicly
in a newspaper or other advertising media.
No expiration on this permission unless notified.

Background Checks

Have you ever been convicted of a felony?

A misdemeanor other than a traffic violation?
If Yes, you will be provided with a space to explain.

A Criminal Background Check may be required of
some volunteers - may we perform a background
check on you?

By selecting Yes, you agree that a background check
may be performed. If needed you will be provided an
area to supply Other Names you may want us to use
durning this check.

By Selecting NO, you agree that do not wish to have a
background check performed. Refusal of a
background check does not automatically eliminate
you from consideration for volunteer service.

Final Details and Submission

State of Ohio Data Base



I understand that by voluntarily providing my information to the Ohio Citizen Corps and the Ohio Medical Reserve Corps, I am indicating a willingness to volunteer during a governmentally declared emergency that requires assistance from the medical community.


Registering with the Ohio Citizen Corps and the Ohio Medical Reserve Corps is not a substitute for the appropriate professional license to practice in Ohio. I understand that it is my responsibility to properly maintain my professional license in good standing and that an Ohio license in good standing and participating in any required training or education is a prerequisite to volunteering.


I further understand that by saying "Yes" I hereby certify and affirm all the information I have provided is true and accurate to the best of my knowledge.


I also acknowledge that the Ohio Citizen Corps and the Ohio Medical Reserve Corps may verify the information I have provided as a part of the volunteering process.


The Ohio Citizen Corps Database is maintained by the Ohio Community Service Council. We are entering your information in this database for you. You are encouraged to use your account we are setting up for you at www.servohio.org The site is set up to allow you to keep your own information current and customize your volunteer
experience. Response is ALWAYS completely voluntary.


Please type your Full Name in the box below




Please note that the registration process can take up to 1-2 minutes. Only press the submit button once. Do not refresh your browser or press the forward or back buttons.

Check the box below if you would like a copy of this registration

form sent to your email address.
           



The District Board of Health is an Academic Health Department Affiliated with the Northeast Ohio Medical University
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