2. Whatcom County Medical Reserve Corps Screening Form
4. First Name*
5. Middle Name*
6. Last Name*
8. Home Phone*
9. Cell Phone
10. Email*
12. Availability

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
    7. Saturday
13. Please provide any additional information about your availability.
17. Skills and Training
19. Are you currently certified as an ACLS and/or BLS provider?

    1. Yes
    2. No
20. If "Yes," certification expiration date:
    If "Yes," certification expiration date:
21. If "No," do you have plans to become current?

    1. Yes
    2. No
23. Are you currently affiliated with a disaster relief organization?

    1. Yes
    2. No
24. If "Yes" list the organization.
26. Are you currently registered as an emergency worker?

    1. Yes
    2. No
27. If "Yes" please provide your Emergency Worker Card Number
29. Credentials*

    1. MD
    2. DO
    3. Paramedic
    4. RN
    5. EMT
30. Other Credentials Not Listed:
31. State Credential Number*
32. Credential Expiration Date*
34. Current Licenses Held
36. Are you currently licensed in Washington State?

    1. Yes
    2. No
37. You will be asked to present your license or certification at a later date.
39. Have you completed ICS Training?

    1. Yes
    2. No
40. If "Yes" Please list the courses you have completed. Separate each with a comma.
42. List special equipment/vehicles/resources you can offer
44. Is there any additional information you would like to share with us?
46. Are you interested in non-medical support? Such as record keeping, training set-ups, etc? Can we reach out with volunteer opportunities?

    1. Yes
    2. No
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field