SAN MATEO COASTSIDE MEDICAL RESERVE CORPS
P.O. BOX 373 - Half Moon Bay - California 94019
Application form
NAME: ______________________________________________________
(PLEASE PRINT)
ADDRESS: ____________________________ CITY: ___________________ ZIP: ______
EMAIL ADDRESS: _____________________________________________________
HOME PHONE: ___________________ CELL PHONE: _____________________
PROFESSIONAL EXPERIENCE: ________________________________________________
___________________________________________________________________
CURRENT HEALTHCARE PROFESSIONAL LICENSE? _______
TRAINING: MILITARY? _____ CERT? _____ RED CROSS _____ CPR _____
FIRST AID? _____ DISASTER RESPONSE? _____
CIVIC ACTIVITIES-COMMUNITY INVOLVEMENT: _______________________________
___________________________________________________________________
CAN YOU ATTEND NIGHT MEETINGS? ________ DAY MEETINGS? ________
HOW DID YOU LEARN ABOUT THE SMC MRC? _____________________________
____________________________________________ _______________
SIGNATURE DATE | 
