The MRC is a partner program with Citizen Corps, a national network of volunteers dedicated to ensuring hometown security. MRC units are community-based and function as a way to locally organize and utilize licensed volunteers who want to donate their time and expertise to prepare for and respond to emergencies. MRC volunteers supplement existing emergency and public health resources. Types of licensed Volunteers Needed:
• Pharmacist • Physicians/PAs • Dental Health Providers • EMT/Paramedics • Veterinarians • Nurses/CNAs •
(Once a member volunteers they will only be called upon during an emergency. Time commitments would consist of possibly of yearly meeting and “Just-in-Time” training before members are deployed.)
YAKIMA COUNTY MEDICAL RESERVE CORPS APPLICATION
Complete and email to kr.catlin@co.yakim.wa.us or mail by standard post (to MRC Coordinator, room 110, 128 North 2nd street Yakima, WA 98901)
VOLUNTEER APPLICATION FORM
PERSONAL INFORMATION
Volunteer Name: ____________________________________________ Home Phone: ___________________________
Office Phone: _________________________Pager: ____________________ Cell Phone: _________________________
Address: ________________________________________________ City ____________________ Zip ______________
Date of Birth: Driver’s License Number:
Email Address:
Affiliations? (School, agency, clinic):________________________________________________________________
EXPERIENCE
Current (Most Recent) Employer: ___________________________________ Supervisor: ________________________
Position: ________________________ Address __________________________________________________________ Phone: _________________________
r Full Time
r Part Time
r Retired
r Other: ________________
If less than one year at current employment, please provide second employer information:
Employer: _______________________________________ Supervisor: ________________________________
Position: ________________________
Address ___________________________________________________________ Phone: _________________________
r Full Time
r Part Time
r Retired
r Other: ________________
PROFESSIONAL INFORMATION: (mark or circle all that apply)
r Administrative/Support Duties
r Computer or Communications
r Dentist
r Emergency Medical Technician: Basic Intermediate Paramedic
r Environmental Health Specialist
r Health Educator
r Health Technician Type ____________________
r Interpreter
r Mental Health Practitioner
r Medical Assistant
r Media/Communications
r Nurse: RN LPN Nurse Practitioner Do you have prescriptive authority? Yes No Area of Specialty:__________________________
r Nurse Assistant
r Pharmacist
r Phlebotomist
r Physician: Area of Specialty: ___________________________ Board Certified? Yes No
r Physician Assistant
r Veterinarian
Professional License Type/Number: _________________________________Expiration Date: ______________________
Professional License Type/Number: _________________________________Expiration Date: ______________________
Other Qualifying License(s) (commercial, equipment etc.) __________________________________________________
Brief description of what you want your role to be in the YC MRC:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OTHER SKILLS
Are you CPR certified? Yes No
Are you first aid certified? Yes No
Other ____________________________________________________________________________________
Language Fluency: q English q Spanish q Sign Language q Other ______________________
Please list any other special disaster training, certification, or skills that you would like us to be aware of:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LEVEL OF PARTICIPATION AND ACTIVATION
Tier One ______ (Activation for Only large-scale events)
Tier Two ______ (Pre-event training as well as the Tier One Activation)
Tier Three _____ (Would like to be considered for a leadership role as well as level Tier Two Activation)
Do you volunteer for another emergency organization? Yes No If so, which is your priority? _________
RESPONSE JURISDICTION (Select the farthest distance you would be willing to respond)
Are you willing to deploy outside your local jurisdiction?
___Yes ___No
___Within Yakima County ___ Within WA St. ___Nationally
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: ______________________________________ Relationship: _________________________
Day Phone: _______________________ Evening Phone: _____________________ Cell Phone: ____________________
Applicants are advised that the Yakima County MRC intends to conduct a criminal background check.
Have you ever been convicted of a drug offense? q Yes q No
Have you ever been convicted of a criminal offense? q Yes q No
Have you ever been convicted of a motor vehicle offense (other than speeding tickets)? q Yes q No
Other than the above, are there any other convictions on your personal record? q Yes q No
Details: ___________________________________________________________________
All of the information that I have supplied is correct to the best of my knowledge. I do hereby give the Yakima Valley Office of Emergency Management (YVOEM) or their designee permission to inquire into my background, references, driving record, present and previous employment, licenses, certifications and criminal history. I further give permission to the holder of any such records to release the same to the YVOEM or their designee. I hold the YVOEM or their designee harmless of any liability, whether civil or criminal, which 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 YVOEM or their designee.
I understand that I am a volunteer and will not be paid for any of my services.
_____________________________________________________ ______________________________________
SIGNATURE DATE
For questions please contact Yakima Valley Office of Emergency Management MRC Coordinator at (509)574-1908
Please send your completed application packet to:
Yakima Valley Office of Emergency Management MRC Coordinator: 128 North 2nd Street, WA 98901
(Back ground Check form)
Yakima Valley Medical Reserve Corps Supplemental Information
For completion of background checks, please supply the following:
Personal References:
Name: ________________________ Contact Ph #: _____________________
Name: ________________________ Contact Ph #: _____________________
Personal References:
Name: ________________________ Contact Ph #: _____________________
Name: ________________________ Contact Ph #: _____________________
Signature ___________________________________ Date ____________________
Yakima Valley Medical Reserve Corps
Background Check Effective Date: ______________
Policy
The Yakima Valley MRC will complete a background check on all applicants to the MRC Team. Record check information is confidential.
Purpose
To comply with the WA Department for Public Health’s recommendation for criminal record checks on team members and to define guidelines that constitute denial of team membership. Record checks protect the citizens in the community as well as team integrity.
Procedure
- All applicants/potential volunteers shall be provided with a criminal background check request form for completion as part of the application process and return it to the MRC Coordinator.
- The services of a potential volunteer shall be evaluated on a case-by-case basis for violations that may show on a criminal record check.
- The following violations constitute grounds for denial of membership of applicants to the team. The services of an applicant shall not be accepted if the criminal record check shows :
- Registration as a sex offender
- Conviction of a felony
- The following violations will be reviewed on a case-by-case basis as outlined below in #5. The services of an applicant may not be accepted if the criminal record check shows:
- Conviction of a misdemeanor in the past 5 years
- Conviction of a criminal violation in the past 2 years
- Conviction of DUI in the past 5 years
- Current EPO or DVO in place
- Case-by-Case Review: Evaluation will determine if past conduct is compatible with working as a MRC volunteer. Consultation may include Yakima Valley MRC Coordinator, Yakima County Health Department Director, Citizen Corp Advisory Board, Emergency Management Director and the Yakima County Attorney. The volunteer shall be given the opportunity to provide evidence of mitigating circumstances prior to a decision being made concerning qualifications to serve.
6. Appeal: Any volunteer whose services are rejected as a result of information received from the criminal record check may appeal such decision if the volunteer believes the decision was based on inaccurate information.
