ESAR-VHP Volunteer Registration for ND PHEVR/MRC
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? YesNo
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.) YesNo
* Date of Birth: (enter as mm/dd/yyyy)
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)
Company:
Job Title:
Department:
Address 1:
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? YesNo
Please list any hospitals where you currently have privileges:
Please list any clinics where you currently have privileges:
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:
Please select all areas of need where your talents or experience applies: AdministrativeSecurity/SafetyLogistics/SuppliesInterpreterCommunication SupportTechnology SupportDriverGeneral Volunteer AssistanceClergyCISMCommunity Chaplain
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.
Emergency Preparedness & Response Section North Dakota Department of Health 1720 Burlington Drive Bismarck, ND 58504 Phone: 701.328.2270 Fax: 701.328.0357 Email: dohepr@nd.gov
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