Personal Information

Prefix:
--Choose-- Mr Mrs Miss Ms Dr Prof Rev Fr Sr Rabbi

* First Name:

* Last Name:

* Email Address:

* Address 1:

Address 2:

* City:

* State:
--Choose-- Minnesota Montana North Dakota South Dakota

* Zip Code:

County of Current Residence:
--Choose-- Adams Barnes Benson Billings Bottineau Bowman Burke Burleigh Cass Cavalier Dickey Divide Dunn Eddy Emmons Foster Golden Valley Grand Forks Grant Griggs Hettinger Kidder LaMoure Logan McHenry McIntosh McKenzie McLean Mercer Morton Mountrail Nelson Oliver Pembina Pierce Ramsey Ransom Renville Richland Rolette Sargent Sheridan Sioux Slope Stark Steele Stutsman Towner Traill Walsh Ward Wells Williams Big Stone, MN Clay, MN Grant, MN Kittson, MN Marshall, MN Norman, MN Otter Trail, MN Pennington, MN Polk, MN Red Lake, MN Roseau, MN Stevens, MN Traverse, MN Wilkin, MN Other

* Phone: (enter as 10 digit number - no punctuation)

Cell Phone: (enter as 10 digit number - no punctuation)

* Have you ever been convicted of a felony or misdemeanor?
Yes
No

If yes, please identify offense and date.

* Are you willing to give your consent to a Criminal Background Check by the appropriate law enforcement agency? (Volunteers may be handling /working with medical/vaccine or other security sensitive products.)
Yes
No

* Date of Birth: (enter as mm/dd/yyyy)

Social Security Requirement

For insurance purposes when volunteers are deployed for events certain information must be submitted at that time. These information items include the volunteer's name and social security number. To be eligible for service we will need that information on all volunteers in advance.

* Social Security Number: (enter as 9 digit number - no punctuation)

Employment Information

Company:

Job Title:

Department:

Address 1:

Address 2:

City:

State:
--Choose-- Minnesota Montana North Dakota South Dakota

Zip Code:

Phone: (enter as 10 digit number - no punctuation)

Do you currently work first hand with patients in a clinical, residential, or other medical setting?
Yes
No

Please list any hospitals where you currently have privileges:

Please list any clinics where you currently have privileges:

Medical Volunteers

Please check your primary qualification/occupation.
--Choose-- APRN LPN RN NP CNA Medical Assistant EMR EMT Paramedic MD DO PA Dentist Dental Assistant Phlebotomist Laboratory Technician Social Worker Veterinarian

In order to serve as a medical volunteer your license or certification must be current, unencumbered, and verified in the Volunteer database.

License or Certification #

Expiration:

Specialty, if any:

Non-Medical Voluteers

Please select all areas of need where your talents or experience applies:
Administrative
Security/Safety
Logistics/Supplies
Interpreter
Communication Support
Technology Support
Driver
General Volunteer Assistance
Clergy
CISM
Community Chaplain

Languages spoken if you are able to serve as an "Interpreter":

Commercial Drivers License number if you selected "Driver":