Emergency Response Volunteer Form

Please complete the form below if you would like to volunteer. Please note if you are a medical volunteer your license must be current, unemcumbered, and verified with Elbowoods Memorial Health Center staff.


First Name^*
Last Name^*
Email Address^*
Address 1^*
Address 2
City^*
State^*
Zip Code^*
County of Current Residence^*
Phone Number^*
Cell Phone
Have you been convicted of a felony or misdemeanor?^*		Yes No
If yes, please identify offense and date
Are you willing to give your consent to a Criminal Background Check by the appropriate law enforcement agency? (Volunteers may be handling/working with medical/vaccine or other security sensitive products.)^*		Yes No
Date of Birth^*
Medical Volunteers
Type of Volunteer		MD DO PA LPN RN APRN Pharmacist Social Worker Phlebotomist CNA
License Number:
State of Licensure
Expiration Date of State Licensure
DEA Number
Expiration Date of DEA
NPI Number
Non-Medical Volunteers
Please select all areas of need that applies:		Administrative Security/Safety Logistics/Supplies Interpreter Communication Support Technology Suuport Driver General Volunteer Assistance Clergy
Languages spoken if you are able to serve as an "Interpreter":
Commercial Drivers License number if you selected "Driver":
I hereby certify that the information contained herein is true, accurate, and complete to the best of my knowledge. Please initial as signature.^*

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Emergency Response Volunteer Form

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Elbowoods Memorial Health Center

1058 College Drive, New Town, ND 58763