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	CAPITOL REGION MEDICAL RESERVE CORPS
	MRC APPLICATION This form may be filled out and submitted automatically be clicking on the Submit button at the end of the form, or it may be printed out and faxed to Katherine McCormack at 860-722-6179, or mailed to Katherine M. McCormack, RN, MPH, MRC Director, City of Hartford, Department of Emergency Services, 50 Jennings Road, Hartford, CT 06120. ALL REQUIRED FIELDS ARE NOTED IN BOLD, BLUE TEXT.

Today's Date
Personal Information
First Name
Middle Initial
Last Name
Suffix, if any
Degree
Street Address
2nd Address Line, if needed
Town
State
Zip Code
Home Phone	- -
Cell Phone	- -
Home Email
Language Fluency, other than English
Do you have a current Connecticut license to operate a motor vehicle?			Yes No
Professional Information
Employment Status	Fulltime Parttime Retired
Employer
Work Street Address
2nd Address Line, if needed
Town
State
Zip Code
Work Phone	- - Extension
Work Fax	- -
Work Email
Occupation (select only one; use space below if more than one or if your occupation is not listed; additional information can be submitted in the last box below)	Physician RN LPN APRN EMT Paramedic Pharmacist		Mental Health Practitioner Psychologist Social Worker Physician Assistant Medical Assistant Dentist Veterinarian
If not listed or if more than one occupation, please specify:
Area of Specialty if any
Do you have a current Connecticut license or certification to practice in your profession and field of specialty?			Yes No
Connecticut License #
Certification #
If a physician, are you board certified?			Yes No
If a nurse, do you have prescriptive authority?			Yes No
Are you part of any other emergency/disaster alert system?			Yes No
If yes, please specify here:
Are you CPR certified?			Yes No
Are you First Aid certified?			Yes No
Are you a member of the Governor's Foot Guard?			Yes No
Are you a member of the Governor's Horse Guard?			Yes No
Emergency Contact Information:
Name:
Telephone number:	- - Extension
Additional Information:

Click to Submit		Due to the vital mission of the Capitol Region - Medical Reserve Corps, it is critical that this form be filled out as thoroughly as possible. All information is kept confidential.
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Capitol Region Council of Governments
241 Main Street | Hartford, CT 06106-5310
Telephone: (860) 522-2217 | Fax: (860) 724-1274