Broward County Medical Reserve Corp. Volunteer Application

Prefix

Name *

First

Middle

Last

Suffix

Birthday *//

Gender

Male
Female

Height

Weight

Address *

Address Line 1

City

State

Zip Code

Phone#1 *

Phone#2

Email *

Emergency Contact Name *

Relationship

Emergency Contact Phone# *

What type of volunteer position are you interested in? (Check all that apply) *

If you selected "Other" for volunteer position, please describe below

List all professional license, registration, or certificate you currently possess (include certificate/license number(s)):

Occupation1

Occupation2

License#1

License#2

Exp. Date#1

Exp. Date#2

Do you have more Occupations to enter?
Yes
No

If yes, please provide details

List any special skills or certifications

List any Special Considerations or needs

List two personal references not related to you whom you have known for more than one year:

Name of 1st Reference
First
Last

Address of 1st Reference
Address Line 1
City
State
Zip Code

Phone# for 1st Reference

Name of 2nd Reference
First
Last

Address of 2nd Reference
Address Line 1
City
State
Zip Code

Phone for 2nd Reference

List your most recent most volunteer or employment experience:

Employer

Employer Address
Address Line 1
City
State
Zip Code

Employer Phone

Job Title

Date Started

Date Ended
Select todays date if still employed or volunteering at this location

Specify the days and time frames you are available to volunteer (Check all that apply):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Select Date you can start

Select Date you need to stop

Have you ever been convicted of or plead nolo contendere to a driving or criminal offense? *
Yes
No

If answer is yes, please explain (including types of offenses and dates):

It shall be a misdemeanor of the first degree to fail to disclose, by false statement, misrepresentation, impersonations or other fraudulent means, any material fact used in making a determination as to a person’s qualifications to work as a volunteer. I understand that, to protect persons served by the department, a routine check through law enforcement, license bureaus, agency files, and references may be made. I understand that a criminal offense will not automatically exclude me from all volunteer positions; however, certain convictions will exclude me from volunteering in some positions. I understand that if I answered no to the criminal offense question on the front of this application and a record should be obtained, it will prevent me from volunteering for the department regardless of the offense. I understand upon submission of this application it becomes public record. I understand and agree that all information as it relates to persons served by the department is to be held confidential in compliance with Florida Statutes. All information that should come to my attention and knowledge as privileged and confidential will not be disclosed to anyone other than authorized personnel and that I shall conduct myself in accordance with the departmental security policies. I understand that failure to comply may result in criminal prosecution. I affirm that all information on this application is true and correct.

Signature *

Todays Date *