MRC_Volunteer_Application

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Tooele County Health Department
151 North Main Street •Tooele Utah 84074•
(435) 277-2457

Medical Reserve Corps Volunteer Application

Home:

Full name:

Street Address:

City:

County:

Zip:

Phone:

Cell:

Fax:

Email:

Work

Employer:

Job Title:

Street:

City:

County:

Zip:

Phone:

Fax:

Email:

Are you under 18 years of age?

Yes (If yes, a parent and/or guardian must sign.

I understand my child will be volunteering with the Tooele County Public Health District.
Parent/Guardian Print Name Here:_______________________________
Parent/Guardian Write Signature Here:___________________________________

Special Skills (Please check all that apply - Add an extra page if necessary

CPR Certified

First Aid Certified

Automated Ext. Defib Certified

Other Medical training and experience (please fill out medical volunteer information sheet)

Counseling/mental health training/certification (please fill out medical volunteer form)

American Sign Language (ASL)

Amateur Radio License (please list license level and call letters here:_______________

Ability to speak/write/understand language other than english (Please List below)
1._____________________2._________________________3._______________

Clergy (list religion/denomination and any counseling training or experience)

Volunteer experience in disaster response and recovery (please list agency name)

Membership in business, civic, professional, or fraternal associations/organizations:

Association:

Position:

Years:

Association:

Position:

Years:

Emergency Contact Information:

Name:

Relation:

Address:

How did you learn about this Volunteer Opportunity:

http://www.tooele-mrc.org

http://www.tooelehealth.org

Neighbor

Professional Agency

Newspaper

Poster

Word of Mouth

Other (Please explain)

Personal/Professional References (Only one reference may be a family member).

1. Family Member: Name: _____________________Relationship____________

Phone: Work ( ) ________ Home: ( ) _______ Cell: ( ) ______

Mailing address:

1. Co-Worker: Name: _____________________Relationship____________

Phone: Work ( ) ________ Home: ( ) _______ Cell: ( ) ______

Mailing address:

1. Friend: Name: _____________________Relationship____________

Phone: Work ( ) ________ Home: ( ) _______ Cell: ( ) ______

Mailing address:

Ethnicity: (This information will be used for marketing purposes only)

Prefer not to answer	Black/African American	Hispanic
Latio	White	Asian
Gender:
Prefer not to answer	Male	Female
Please read the following statement below and sign underneath: The Tooele County Health Department does not discriminate against any individual on the basis of race, color, religion sex, national origin, age, disability, political affiliation, or belief. I hereby authorize the verification of all necessary information, including employment, education, licensure (where applicable), criminal history, driving record, written or verbal information from references, and any other pertinent information related to this volunteer position. I certify that my answers to these questions are true and complete and that I have not knowingly withheld any information. I understand that any misrepresentation or omission of facts on this application may be cause for non-selection, or dismissal.
Signature:		Date:
Please mail or fax this completed form to: Bucky Whitehouse, PIO/Emergency Planner, or Kristen Bolinder, Emergency Preparedness Assistant, at the Tooele County Health Department, 151 North Main Street, Tooele, Utah 84074 (435 - 277-2457) (Fax 435-277-2444.)