Center for Disaster Medicine : UNM HSC SOM

New Mexico Medical Reserve Corps

Volunteer Interest Application

The New Mexico MRC units are currently recruiting volunteers with medical and non-medical backgrounds. Volunteers can choose to participate only during a public health emergency or disaster, or to also participate in year-round public health initiatives. If you are interested in volunteering, please complete and submit the form below. If you are unable to fill out the application online, you can email LEsquibel@salud.unm.edu, or call 505-994-9560 and fill out the application over the telephone. When your application is received, you will be contacted to discuss volunteer opportunities within the many New Mexico MRC units.

Please enter your information on the following form and click on the Submit button at the bottom of the page. If you wish to print out a copy of your completed form, fill in your information, but before you submit it, go up to your file menu and choose "print" or click on the print icon. Then click on the Submit button below.

Note: By submitting this information, you are NOT committing to be an MRC volunteer. All information submitted will be reviewed only by the New Mexico MRC volunteer review team.

Applicant Information **Required fields
**Last Name:
**First Name:
**Work Address:
**City:
**State:
**Zip Code:
Home Address:
City:
State:
Zip Code:

**Work Phone:	Area Code: Phone:
Home Phone:	Area Code: Phone:
Cell Phone:	Area Code: Phone:
Pager:	Area Code: Pager:
DOB Day / Month / Year

**E-mail Address:
Fax:	Area Code: Phone:

License Information
**I am licensed/certified as one of the following:
If "Other" please indicate in what:
**Expiration Date:	(Please use mm/dd/yy format)
Area of Practice	School..? COP, CON, SOM etc

Additional Information
Disaster training received:
Language fluency:
Person to be notified in case of emergency:
Emergency Contact Phone:	Area Code: Phone:

Interests or Comments: In what capacity would you be willing to assist.?
Have you ever been convicted of, pled guilty to, or been charged with a felony offense?	Yes No
If yes, please describe. You are under a continuing obligation to immediately update your response to this question if your circumstances change after you submit this application.
Do you consent to a background check?	Yes No

**If the information is correct, please type "yes" here:
To send us this information, click on the Submit button, or print first, and then, click on the Submit button below.