Southern Seven Health Department
Southern 7 County Medical Reserve Corps (S7MRC)
Application
“The mission of Southern 7 County Medical Reserve Corps (S7MRC) is to engage health care professionals and other volunteers in helping the
community prepare for, respond to, and mitigate emergencies, disasters, and pressing public health needs.”
“There is no greater calling than to serve your fellow man” – Walter Reuther
Name: ________________________________________
Primary Phone: __________________ □ home □ cell
Date: _____/_____/_______
Alt. Phone: ___________________ □ home □ cell
Address: _______________________________________ Email: _____________________________________
Please answer to the best of your ability
Have you ever been a volunteer or employee with us?
□ YES
□ NO
If yes, please explain:
Have you ever been convicted of a crime (a criminal
background check will be required. Prior arrest or
conviction will not necessarily disqualify a volunteer
applicant)?
□ YES
□ NO
Are you currently a student or employed?
□ Student
□ Employed
□ Retired
Are you able to receive text messages for emergency
alerts/drills?
□ YES
□ NO
MUST PROVIDE TO RECEIVE TEXT ALERTS:
Would you be willing to use your vehicle for volunteer
tasks?
□ YES
□ NO
Do you have any specific medical or physical
limitations that requrie accomodation?
□ YES
□ NO
If yes, you may need to provide proof of
insurance at a later date.
If yes, what accomodation(s) do you need:
Please list where:
Please provide your carrier (ex. Verizon, Alltel):
Why do you want to join the Medical Reserve Corps?
How did you hear about the Medical Reserve Corps?
If you are a licensed health care provider, please indicate which license:
□ Physician (M.D./D.O.)
□ LPN
□ PA
□ Pharmacist
□ NP
□ Dentistry/Optometry
□ Mortician
□ Veterinarian
□ RN
□ Other Public Health/ Medical:
□
□
□
□
Mental Health Professional
EMS Professional
Respiratory Therapist
Non- Public Health/ Medical
Current active professional license #: ______________________ Driver’s License #: ____________________
Please check any skills/background you have in the following areas:
□
□
Clergy/Counseling
Technical (please specify) :
□
□
Data entry/ Bookkeeping/Secretarial
Telephone reception
□
□
Desktop publishing
HAM- Amateur Radio Operator
□
□
Training/presenting/public speaking
Working with the public
□
□
Attorney/Legal
Mechanic/ Construction/Labor
□
□
Interpreter or sign language:
Security/Enforcement
□
□
Military
IT/ Computer Hardware and Software
□
Other (please specify):
Please check the counties that you will most likely be able to volunteer*:
Alexander Pulaski Union
Johnson
Massac
Pope
Hardin
Other/Outside of
these counties
Yes
Maybe
No
*In the event of a real emergency, all MRC members will be called. This box is to indicate what non-emergency
volunteer and training opportunities you would be available for.
Level of Involvement: Please check all that apply:
□ Any volunteer activities
□ Public Health (non-emergency events)
□ Emergencies only
Is there a time limit of availability?
(example- 1 semester, this year, summers only, etc.): __________________
I understand that this is an application for a volunteer position and I will not be paid for my services. I
understand that this information will be entered into the Illinois HELPS- Illinois Healthcare Professional
Emergency Volunteer Program which is Illinois’ Emergency System for the Advance Registration of Volunteer
Health Professionals (ESAR-VHP). By my signature below, I certify that the information I have provided on this
application is true and correct.
Signature: ____________________________________
Date: ___________________
Please return to:
Southern 7 Health Department
Attn: Allison Hasler
37 Rustic Campus Dr.
Ullin, IL 62992
mrc@s7hd.org
Fax: (618) 634-9394
OFFICIAL USE ONLY:
Routing Procedures (initial each step):
Division Director: ____ Executive Director: ____
HR: ____
AUTHORIZATION TO RELEASE INFORMATION
Please Type or Print Legibly
I, ___________________________
__________________________
__________________________
_________________________________________________________
__________________________
Last Name
Current Address
First Name
Dates Lived Here
Addresses for the Past Seven Years: (include street, city, state, zip code)
Middle Name
Dates of Residence:
________________________________________________________________________
____________________________
________________________________________________________________________
____________________________
________________________________________________________________________
____________________________
________________________
Date of Birth
_______________________________________
Other Names Used (including maiden name)
____________________________
Years Used
________________________
Social Security Number
_______________________________________
Driver’s License #
____________________________
State
_______________________________________
Email address
do hereby authorize verification of all information in my employment application from all sources of employment, education, motor
vehicle, financial history, criminal history, personal character, and worker’s compensation records in accordance with ADA, labor and
wage records, etc. or any part thereof, and authorize any duly authorized agent of IntelliCorp Records, Inc to obtain, whether
the said records are public or private, and including those which may be deemed to be privileged or confidential in nature and I
release all persons from liability on account of such disclosures. Information appearing on this Authorization will be used exclusively
by IntelliCorp Records, Inc for identification purposes and for the release information which will be considered in determining
any suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment
application, any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application
for employment. I agree to provide additional information that may be requested to process my employment application. I
authorize without reservation, any party or agency contacted by IntelliCorp Records, Inc to furnish the above-mentioned
information. This authorization is valid during the course of my employment to the extent permitted by law.
**I hereby do _____do not_____ authorize you to contact my current employer for Employment and Reference Verifications. (This
will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the
Employment/Reference Section of your application).
I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance
of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on
me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.
I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any
supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.
__________________________________________
Printed Name
_________________________________________
Applicant Signature
__________________
Date
DISCLOSURE
As part of our hiring background and investigation, we may obtain consumer reports or prepare an investigative consumer report.
The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may
also include, but not be limited to, credit information reports, criminal history reports and driving history records. Under the
provision of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have
your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure
of the nature and scope of the investigation. You are also entitled to a copy of your Rights Under the Fair Credit Reporting Act.
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A, 600 Pennsylvania Ave. N.W.,
Washington, DC 20580.
Summary of Your Rights under the Fair Credit Reporting Act
(Keep this copy)
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer
reporting agencies (CRAs). There are many types of consumer reporting agencies, including credit bureaus and specialty agencies
(such as agencies that sell information about check writing histories, medical records, and rental history records). Below is a
summary of your major rights under the FCRA. For more information, including information about additional rights, go to
www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600
Pennsylvania Ave. N.W., Washington, DC 20580.
• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type
of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you –
must tell you, and must give you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all information about you in the files of a
consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your
Social Security number. In many cases, the disclosure is free of charge. You are entitled to a free file disclosure if: o a person has
taken adverse action against you because of information in your credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

you are unemployed but expect to apply for employment within 60 days.
In addition, since September 2005, all consumers are entitled to one free disclosure every 12 months upon request from each
nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional
information.
• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on
information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute
scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit
score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is
incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate it unless your dispute is
frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate,
incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting
agency may continue to report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting
agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid
need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those
with a valid need for access.
• You must give your consent for reports to be provided to employers. A consumer reporting agency may not disclose
information about you to your employer or a potential employer without your written consent to the employer. Written consent
generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.
• You may limit “pre-screened” offers of credit and insurance based on information in your credit report. Unsolicited
“pre-screened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your
name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5OPTOUT (1-888-567-8688).
• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a
furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have additional rights. For more information, visit
www.ftc.gov/credit.
States also may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you
may have more rights under a state law. For more information, contact your state or local consumer protection
agency or your state Attorney General. Federal enforcers are:
As of January 1, 2012, employers or prospective employers in the states of California, Connecticut, Hawaii,
Illinois, Maryland, Oregon, and Washington are prohibited from obtaining a consumer credit report unless the
information contained in the report is required by law or is substantially job related, and the reason(s) for using
the information are disclosed to you in writing.