Volunteering with the Boone County MRC

Volunteer Application Form

You can begin your volunteer application right here online! Completing the application takes about 5 minutes. Once you've started your application, please be ready to complete it all at once.

All information you supply us is confidential and transmitted over a secure and encrypted connection, so your personal information can't be stolen or lost in transmission. In addition, your personal information isn't stored on this website forever, either.

Volunteers must consent to a background check and a confidentiality form.

Personal Information

What can we call you?

Title:(optional) First Name:(required) Middle Initial:(optional) Last Name:(required)

What is your home address?

Street Address Line 1:(required) Street Address Line 2:(optional) City:(required) State:(required) Zip Code:(required)

How can we contact you?(At least one required)

Home Phone Number: Mobile Phone Number: Work Phone Number: Fax Number: Email Address:

What are your contact preferences?

How can we contact you by phone?(At least one required)

Home Phone
Mobile Phone
Work Phone

What other contact methods do you prefer?(optional)

Fax
Email

Who is your emergency contact?

Emergency Contact Name:(required) Emergency Contact Phone:(required) Relationship:(optional) Additional Emergency Contact Information:(optional)

Tell us your employment information

Your Job

Primary Occupation:(required)

Occupation Status(required)

Full Time
Part Time
Retired
Student

Employer Contact Information

Employer Name: Employer Address Line 1: Employer Address Line 2: Employer City: Employer State: Employer Zip: Employer General Phone Number: Your Phone Extension at Employer: Employer Fax Number:

License Status(required)

Current, active license
Inactive license
Not Applicable

Professional License Details

Note: this information is for professional license numbers only, not operator or driver license numbers.

Professional License Number(RN, MD, RPh, etc., if applicable)

Certifications and Training

Check all that apply

CPR Training

Date

Agency

First Aid Training

Date

Agency

Disaster Training

Date

Agency

Incident Command System

Date

Agency

CERT

Date

Agency

Other Certifications

Describe other certifications

Volunteer Experience

Describe previous/volunteer experience:

Skills

Are you biligual?(required)

Yes
No If yes, in what language(s)? Computer Skills(optional) Other Skills(optional)

Areas of Interest

Please indicate area of interest (check all that apply)

Greet Patients
Register Patients
Assist with Vaccination
Medical Screening
Assist with Clinic Flow
Forms Completion/Clerical
Data Entry/Computer Support
Supply/Stock
Other, please describe

Other

Shirt Size (required)

S M L XL 2XL 3XL

Background Check

Have you ever been convicted of a misdemeanor (other than a traffic violation)?(required)

Yes No

Have you ever been convicted of a felony?(required)

Yes No

If yes, please describe:

Authorization

A Criminal Background Check is required of all volunteers

Birth Date(required) Country of Birth(required) State of Birth(required) Maiden Name(required) Print Your Name (required)
(Typing your name serves as your digital signature) Date(required)

All done? or

Volunteering with the Boone County MRC

Volunteer Application Form

What can we call you?

What is your home address?

How can we contact you?(At least one required)

What are your contact preferences?

Who is your emergency contact?

Your Job

Employer Contact Information

License Status(required)

Professional License Details

Check all that apply

Volunteer Experience

Please indicate area of interest (check all that apply)

Shirt Size (required)

Have you ever been convicted of a misdemeanor (other than a traffic violation)?(required)

Have you ever been convicted of a felony?(required)

If yes, please describe:

A Criminal Background Check is required of all volunteers

Oops, we have some errors.

Application Successfully Received!