Sacramento Medical Reserve Corps Foundation
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Volunteer Application
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Sacramento Medical Reserve Corps
Volunteer Application
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Indicates required field
Which classification best describes you?
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Community Health Volunteer (non-medical)
Health Care Professional (medical)
Personal Information:
First Name
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Middle Initial
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Last Name
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address
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.
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City
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county
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State
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Zip Code
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Home Phone Number
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Cell Phone Number
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Work Phone Number
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Email Address
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Gender
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Male
Female
Date of Birth
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Driver's License Number
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Please attach a copy of your photo ID
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Max file size: 20MB
Employer
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Emergency Contact
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Emergency Contact Phone Number
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Medical conditions the SMRC should be aware of, including allergies
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Are you willing to volunteer outside of our region in the event of an emergency
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Yes
No
Maybe
Are you able to stand for extended periods of time (3+ hours)
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Yes
No
Are you able to volunteer 12 to 24 hours at a time, if activated for an emergency?
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Yes
No
Can you lift 20 to 25 pounds?
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Yes
No
How did you learn about the Sacramento Medical Reserve Corps?
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Internet Search
Advertisement
Bus Advertisement
Next Door
Friend
Other
If Other please specify:
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Skills
Health Care Professionals:
Licensed / Certified as
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Name on License or Certification
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License / Certificate #
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Licensing Agency and State
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Expiration Date
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List any specialties within your professional licensure
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Do you have prescriptive authority?
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Yes
No
Do you carry malpractice insurance
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Yes
No
Please upload a copy of your license or certification
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Max file size: 20MB
Do you speak or write languages other than English?
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Yes
No
If yes, please list other languages
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Are you Licensed as an amateur Radio Operator
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Yes
No
If yes, please list license level and call letters
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Please list any other skills you bring to the Sacramento Medical Reserve Corps
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Training / Continuing Education
Check Areas Where you have completed training
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Blood Borne Pathogens
CPR/AED
Disaster Preparedness Training
First Aid
Incident Command Training (ICS)
National Incident Management Systems (NIMS)
Psychological First Aid
START Triage
None of the Above
Other Training
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By submitting this application,
I hereby certify that all the information shown above is accurate and correct and I hereby make
application for membership in the Sacramento Medical Reserve Corps. I understand that a background check will be completed and submitting this application does not guarantee acceptance into the Medical Reserve Corps.
I understand that I am applying for a volunteer position and that this is not an application for, or contract of, employment. Volunteer positions may be terminated for cause and conduct for benefit of the program.
I understand that I may have access and exposure to confidential health information as a volunteer for the Sacramento Medical Reserve Corps and that HIPAA confidentiality policies apply.
Completion of a Disaster Service Worker form is required. The Sacramento Medical Reserve Corps intends to mitigate the risk of injury and to prevent injuries to its registered volunteers resulting from their participation in the Medical Reserve Corps. Every attempt will be made to reduce any risk of injury through training, education, and use of universal precautions. In addition, volunteers will only be matched to positions for which they have the skills and qualifications to fulfill safely.
Be aware, however, that some unanticipated risk possibilities may be present both during a public health emergency and during non-emergency work with direct patient contact. Medical Reserve Corps volunteers agree to assume any and all risk of injury or damage resulting from any accident or incident encountered as a volunteer. Any incidents, accidents or injuries should be reported to the Program Coordinator immediately.
I agree to receiving marketing and promotional materials
Submit
Home
Get Involved
Support
You Are The Help Until Help Arrives
Contact
Calendar
Volunteer Application