FL MRC Basic Volunteer Contact Form

Select one of the FL MRC Units below that you would like to join or become a member *

Contact Information:

First Name *

Middle Name *

Last Name *

Suffix

Address:

Work Location: Example - Hospital Name, Clinic Name, Florida Department of Health

Work Street Address: Line 1

Work Street Address: Line 2

Work City

Work County

Work Zip

Home Street Address: Line 1

Home Street Address: Line 2

Home City *

Home County *

Home Zip *

Contact Numbers:

Work Phone Number

Work Phone Number Extension

Work Cell Phone Number

Personal Cell Phone Number

Home Phone Number

Email Address :

Work Email Address

Personal Email Address *

Occupations:

Professional Background & Occupation Category (1): Primary

License Prefix: Example: EMT, RN, CNA

License Number

Occupation Professional Status

Professional Background & Occupation Category (2): Secondary

License Prefix: Example: EMT, RN, CNA

License Number

Occupation Professional Status

Are You A Current Member Of The Federal Government's National Disaster Medical System Team (NDMS)

List All Volunteer Health Professional/Emergency Preparedness Affiliations (Local)

List All Volunteer Health Professional/Emergency Preparedness Affiliations (State)

List All Volunteer Health Professional/Emergency Preparedness Affiliations (Federal)

Please feel free to contact HelpFL@flhealth.gov if you have any questions or need assistance with completing this form. Once you have submitted your FL MRC Basic Contact Form, you will be contacted by your Local MRC Coordinator.

Join Today to become a FL MRC VOLUNTEER!

FL MRC Network Website:www.floridamrc.com

Steps to join the FL MRC Network

1. Complete and submit the FL MRC Basic Contact Form to join the FL MRC Network.

2. Locate the closest local FL MRC Unit and FL MRC Coordinator in your area.

3. Review and complete the FL MRC Volunteer required trainings and paperwork.

4. Once you have completed all of the FL MRC Volunteer requirements, your contact information will be added to the Florida Department of Health’s Alerting & Notification System (State ESAR-VHP Responder Registry – Everbridge SERVFL Application).

Note : A background check will be conducted at the local level.