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Annual Flu Clinic - Nov. 11th 8-12noon
The Boards of Health of the six
Vineyard towns announce the
“Annual Flu Clinic” to be held on
Veteran’s Day, November 11, 2010
at the Regional High School.
Save the date!!!

The Martha’s Vineyard Medical Reserve Corps needs medical and nonmedical
volunteers to assist at flu clinics, participate in shelter activities,
train to be communication/radio operators and assist in strengthening
public health and preparedness systems.


Martha’s Vineyard Medical Reserve Corps
Volunteer Application
Personal Contact Information
Last Name _ _____________________________________ First Name ______________________________________ MI ________
Home Address _ ________________________________________ Mailing Address ________________________________________
City _ __________________________________________________ State ______________________ Zip Code _ _______________
Home Phone _ __________________ Cell _ ___________________ Date of Birth ____________ (This is necessary to do a CORI check.)
In Case of Emergency, please contact:
Name _______________________________________________________________ Relationship ____________________________
Daytime Phone ______________________________________ Evening Phone _____________________________________________
Are you currently employed? o Full Time o Part Time o Retired o Student
Education (Circle highest level)
Type of Degree ____________ Major/Specialization ________________ Professional License # _______________ Type ____________
Have you had your professional license suspended or revoked? o Yes o No
Certification and Training (Date of most recent)
CPR _______________________________ Incident Command System – 100 ____________________
CERT ______________________________ Incident Command System – 200 ____________________
First Aid ____________________________ NIMS – 700 Training _____________________________
Standard Precautions __________________ Disaster Training _________________________________
Emergency Response __________________ Other Training __________________________________
What languages do you speak or understand other than English? Please list and indicate level of fluency: (Include sign language)
o Excellent o Fair o Poor
Volunteer Interests
o Clinical Work o Deliveries o Fundraising o Administration Health Education
o Newsletter Production o Phone Bank o Volunteer Coordination
Please list three references that are familiar with your qualifications/experience. Do not list relatives.
Name ________________________________________________________ Phone Number _ ________________________________
Address _____________________________________________________________________________________________________
Name ________________________________________________________ Phone Number _ ________________________________
Address _____________________________________________________________________________________________________
Name ________________________________________________________ Phone Number _ ________________________________
Address _____________________________________________________________________________________________________
All of the information that I have supplied is correct to the best of my knowledge. I do hereby give my local Medical Reserve Corps (MRC)
permission to make inquiries concerning my references, licenses, certifications and police record. I further give permission to the holder of
any such records to release the same to the MRC. I hold the MRC harmless of any liability, whether civil or criminal, that may arise as a
result of the release of the information about me. I also hold harmless any individual agency, business or corporation that provides information
to the MRC.
Signature __________________________________________________________________ Date ____________________________

Please mail or fax application to:
Jean M. Roma, MSN, APRN-BC
Director Martha’s Vineyard Medical Reserve Corps
RR #1, Box 860, Vineyard Haven, MA 02568
Telephone: 508-375-6641 • Fax: 508-362-2603

The County of Dukes County PO Box 190, Edgartown, MA 02539
Phone: 508.696.3840    Fax: 508.696.3841
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