ESAR-VHP Enrollment

ESAR-VHP Volunteer Registration for ND PHEVR/MRC

ESAR VHP Volunteers

Personal Information


* First Name:

* Last Name:

* Email Address:

* Address 1:

Address 2:

* City:

* State:

* Zip Code:

County of Current Residence:

* 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?

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.)

* 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


Job Title:


Address 1:

Address 2:



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?

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.

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 #


Specialty, if any:

Non-Medical Voluteers

Please select all areas of need where your talents or experience applies:

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

Commercial Drivers License number if you selected "Driver":

Thank you for registering and expressing your interest in supporting our State Volunteer program.



Health Department Logo