MRC Responder Interest Form



If you have any questions, please do not hesitate to contact the NENC MRC staff.



Don’t forget to visit ServNC (North Carolina State Registry of Volunteers) to fill out your full application.

If you prefer to complete a paper copy of the NENC MRC Interest Form please click below.




 After completing the paper responder interest form
please mail to:

NENC MRC
PO Box 189
Elizabeth City, NC 27907
or Fax: 252-337-7922

or simply complete the following online responder interest form and press submit.

*Full Name:
*Date of Birth:
/ /
*Street Address (Physical):
*City:
*State:
*Zip Code:
 
Please enter your mailing address.       
*Mailing Address:
*City:
*State:
*Zip Code:
 
Please enter the following contact information.
Home Phone:
Work Phone:
Cell Phone:
Email:
     
Driver's License #:
 
Employer:
 

Emergency Contact Information

*Full Name:
*Address:
*City:
*State:
*Zip Code:
 

The NENC MRC needs all types of volunteers, not just medical volunteers. Please note any special skills that you may have (example: physician, electrician, plumber, health educator, carpenter, etc.)

 

Volunteer Interests

Check all that apply.

If Other please specify:
 

Level of Participation Desired:

I prefer to be ...


Receive notifications of ALL training opportunities, training drills & exercises, emergency events, as well as non-emergency volunteer opportunities.


Receive only notifications of training, drills & exercises and all emergency events
 

Location Preference for Responding

Check all that apply.
 
*Have you been convicted of a crime?     

If Yes please explain:
 
* I do hereby give the Northeast North Carolina Medical Reserve Corps permission to release personal information with local, state and federal emergency management agencies and other Health and Human Service agencies as needed.

Enter the code to the right.
(not case sensitive)


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Privacy Act Statement: This information is requested by the Northeast North Carolina Medical Reserve Corps and is for the purpose of organizing responders and staff to respond to public health emergencies. It will not be utilized or released for any other purpose without your express written permission unless required by law and all information will be kept in a secure manner.