Join the Yakima Valley Medical Reserve Corps
• The MRC was founded after President Bush’s 2002 State of the Union Address, in which he asked all Americans to volunteer in support of their country. It 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 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.
• MRC volunteers include medical and public health professionals such as physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists.
Types of Volunteers Needed:
• Pharmacist • Physicians/PAs • Dental Health Providers • EMT/Paramedics • Veterinarians • Nurses/CNAs •
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YAKIMA COUNTY MRC APPLICATION
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? (eg., school, agency, clinic):________________________________________________________________
EXPERIENCE
Current (Most Recent) Employer: ___________________________________ Supervisor: ________________________
Position: ________________________ Address __________________________________________________________ Phone: _________________________
Full Time
Part Time
Retired
Other: ________________
If less than one year at current employment, please provide second employer information:
Employer: _______________________________________ Supervisor: ________________________________
Position: ________________________
Address ___________________________________________________________ Phone: _________________________
Full Time
Part Time
Retired
Other: ________________
PROFESSIONAL INFORMATION: (mark or circle all that apply)
Administrative/Support Duties
Computer or Communications
Dentist
Emergency Medical Technician: Basic Intermediate Paramedic
Environmental Health Specialist
Health Educator
Health Technician Type ____________________
Interpreter
Mental Health Practitioner
Medical Assistant
Media/Communications
Nurse: RN LPN Nurse Practitioner Do you have prescriptive authority? Yes No Area of Specialty:__________________________
Nurse Assistant
Pharmacist
Phlebotomist
Physician: Area of Specialty:___________________________ Board Certified? Yes No
Physician Assistant
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: English Spanish Sign Language 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)
County of Residence _____ State of Washington _____ United States _____
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 background check.
Have you ever been convicted of a drug offense? Yes No
Have you ever been convicted of a criminal offense? Yes No
Have you ever been convicted of a motor vehicle offense (other than speeding tickets)? Yes No
Other than the above, are there any other convictions on your personal record? Yes 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
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Confidentiality Statement
Yakima Valley Medical Reserve Corps
The Yakima Valley Medical Reserve Corps provides services to our community that may be sensitive in content. Per HIPPA (Privacy Act) regulations, we request to you sign and return the following document to your unit coordinator for placement in your file, indicating that you will keep information to which you have access confidential and not discuss it with anyone other than the staff person with whom you are working.
Confidentiality Pledge
I, ___________________________________ certify that I have read the following statement as listed below and agree to comply with the terms.
I realize that, as a Registered Emergency Worker in the State of Washington, the Department of Emergency Management and the Public Health Department for the Yakima Valley Medical Reserve Corps, I may acquire knowledge of confidential information from files, case records, missions, conversations, etc. I agree that such information is not to be discussed or revealed to anyone not authorized to have the information.
Signature: _______________________________________ Date: ____________
IRIS # : __________________
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Photograph and Media Consent
The Yakima Valley Medical Reserve Corps
The Yakima Valley Medical Reserve Corps may take photos, videos or otherwise document volunteers in action during trainings, exercises and or actual events. Such photographs may be used on the website, in newsletters and other publications without compensation to the volunteer or his/her representatives.
This consent does not apply to photos required for security identification.
Please choose the appropriate section:
The Yakima Valley Medical Reserve Corps has my permission to use my photo as stated above.
Signature: _______________________________________ Date: ____________
The Yakima Valley Medical Reserve Corps does not have my permission to use my photo as stated above.
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:
kr.catlin@co.yakima.wa.us
or
Yakima Valley Office of Emergency Management MRC Coordinator: Room b-10, 128 North 2nd Street, WA 98901
