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Bureau, Putnam and Marshall County Health Departments Bureau, Putnam and Marshall County Health Departments
(815) 872-5091  |  526 Bureau Valley Pkwy.  |  Princeton IL
(815) 925-7326  |  220 East High St  |  Hennepin IL
(309) 246-8074  |  319 6th St  |  Lacon IL

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Medical Reserve Corps Volunteer Form

If you would like to participate in the MRC, please fill out the registration form below. We ask that you complete as much information as possible.

If you would rather submit a printed volunteer form, please use our Printable MRC Volunteer Application.

* denotes required field

Personal Information










Current Employment Information

Please enter your current Employment and Professional information below where applicable.








Participation Role:

ACTIVE - Receive notifications of ALL training opportunities, training drills & exercises,emergency events, as well as non-emergency volunteer opportunities

LIMITED - Receive only notification of training drills & exercises and all emergency events

Please select the level of MRC participation you wish to fullfill.

Volunteer Interests:

Please select all roles you have interest in fullfilling.

Administration
Public Safety
Clinical
Fundraising
Database

Volunteer Coordination
Behavioral Health
Distribution
Clerical Help

Emergency Contact Information

Please enter information for the individual you wish to be contacted in the event of an emergency.







Background Check Authorization

A Criminal and Sexual Background Check is required of all volunteers!

I do hereby give Region V Medical Reserve Corps permission to release personal information with local, state and federal emergency management agencies and other Health and Human Service agencies as needed.

Privacy Act Statement

This information is requested by Region V Medical Reserve Corps and is for the purpose of organizing volunteers and staff to respond to public health emergencies. It will not be utilized or released for any other purpose without your express written permission unless required by law and all information will be kept in a secure manner.

I understand and agree to the MRC Privacy Act Statement

Sign and Submit



If you have any questions regarding this form, please contact Kurt Kuchle by phone at (815) 872-5091 ext 216, by fax at (815) 872-5092 or by email at kkuchle@bchealthdepartment.org

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Bureau, Putnam and Marshall County Health Departments,
All Rights Reserved

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