Please complete all registration questions.

Full Name:
Street Address:
City:
State/Prov:
County:
Zip/Postal Code:
Phone:
Email:
Are you a DeKalb County resident?
yes no

Do you have any emergency training?
yes no
Are you interested in receiving training?
yes no
Are you 18 years of age or older?
yes no

Please list any training and certifications below (please list whether certifications are current):

By submitting this form, the sender consents to release of his or her name, address and contact information to the DeKalb County Board of Health's Medical Reserve Corps. If you do not agree, please click on "Reset" below.

Privacy Act Statement
In compliance with the Privacy Act of 1974, the following information is provided:
The collection of this information is authorized by 5 U.S.C. 301 and Section 2, Executive Order 13254, January 29, 2002. The primary purpose of the form is to provide a means that allows individuals to indicate their interest in volunteer services. Users may also elect to be provided with additional information about other service opportunities. Providing this information is voluntary. All information submitted by a user is available to DeKalb County Board of Health's Volunteer Services.

For more information contact Jenelle Nurse at (404) 294-3862 or by email at
jdnurse@gdph.state.ga.us .