Medical Reserve Corps Application

Medical Reserve Corps Application

Background Information
Last Name / First Name / Middle Initial
Address / City / State and Zip
Home Phone
( ) / Work/Cell Phone
( ) / Fax Number
( )
Email Address
Employer / Job/Title
Social Security Number for Criminal Background Checks: / Date of Birth for Criminal Background Checks:
Drivers License Number: / State of Driver’s License Number Issued:
Do you have a Medical License?
 Yes  No  Active / License Number / Expiration Date
/ / / State Issued
Do you have a health care professional license?
 Yes  No  Active / License Number / Expiration Date
/ / / State Issued
Additional Information
Has your license ever been revoked or suspended?
 Yes  No / If Yes, Please explain in the provided space. / Are you licensed to operate a motor vehicle in the state of Illinois?
 Yes  No
Have you ever been convicted of felony?
 Yes  No / If Yes, please explain in the provided space.
Have you ever been convicted of a misdemeanor, including a DUI, that resulted in imprisonment in the last 24 months?
 Yes  No / If Yes, please explain in the provided space.
Please provide the names and contact information of two personal references
Name / Name
Address / Address
City, State, and Zip / City, State, and Zip
Phone Number
( ) / Phone Number
( )
Email Address / Email Address
Check the box that indicates how frequently you would like to volunteer:
 Occasionally  Regularly  Only in an emergency / Are you interested in attending trainings or participating in practice drills? (participation at a minimum of events is required)
 Yes  No
Are you obligated to another emergency /disaster response team (hospital, Red Cross, etc?
 Yes  No If yes, identify obligation______
Immunizations Received:
 Tetanus (Date_____)  Smallpox (Date_____)  Anthrax (Date______)  Other______
Do you have any special considerations or medical restrictions you want to tell us about?

. Statement of Understanding

I agree and understand that any work that I perform on behalf of the Vermilion County Medical Reserve Corp / Vermilion County Health Department will be provided on a voluntary basis, and that I do not expect payment or other compensation for performing such work. I further understand and agree that a volunteer position does not constitute an employee-employer relationship with the Vermilion County Medical Reserve Corp / Vermilion County Health Department, and that the Department may terminate my volunteer status at any time. The Vermilion County Medical Reserve Corp / Vermilion County Health Department is under no obligation to reimburse me for training or duty related expenses.

I have volunteered to assist the Vermilion County Health Department in cases of emergency. Due to the nature of the work involved the Department has requested certain information. I voluntarily agree to provide such information and waive any right to file a suit about providing the requested information. I understand that I am not required to answer any question or volunteer for any service nor is the Department required to accept my application as a volunteer. The information requested shall be confidential and used solely for the purposes of the Department in establishing the Medical Reserve Corp.

I realize that the Vermilion County Medical Reserve Corp / Vermilion County Health Department is depending on my services and that if for any serious reason I cannot keep my volunteer commitment, I will notify my supervisor in advance of my agreed upon reporting time.

I certify that I am at least 18 years of age. I acknowledge and accept the obligation to serve the public while maintaining the highest ethical standards in both personal and official conduct.

I certify that all statements made in this application are true. I understand the Vermilion County Medical Reserve Corp / Vermilion County Health Department reserves the right to accept or reject my application in its sole discretion.

I have read and understand and will comply with the Vermilion County Medical Reserve Corp / Vermilion County Health Department policies regarding the following areas:

Confidential Information: You may be exposed to sensitive information during your assignment as a Volunteer. Remember, official business of this Department is confidential. Members shall discuss or give official information only to persons for whom the information is intended, as directed by supervisors or as required by law. The content of any criminal record filed on the Department shall be shown or divulged only to authorized personnel.

INJURIES: If you are injured on the job, you should immediately report your injury to your supervisor.

Volunteers will need to use their own insurance policies for any injuries that occur while volunteering for the Vermilion County Medical Reserve Corps.

______

Volunteer Signature Date

Application Verification and Oath Requirement

Application Verification

1. The information provided is complete and true. If information given on this application is untrue or incomplete, I understand my assignment maybe terminated.
2. I have disclosed any felony conviction. I agree to a criminal background, verification of the statements contained herein and additional screening procedures. I understand this may include my references, licenses, police records, and employment and volunteer history. I also give permission for the holder of any such information released to this agency. If requested, I will get a local background check done through the PublicSafetyBuilding and am responsible for the $1.00 fee.
3. I hold this agency harmless of any liability, criminal or civil, which may arise as a result of this information about me. I also hold harmless any individual or organization that provides information to this agency. I understand that this agency will use this information only as part of its verification of my volunteer application.
4. I understand that my own insurance will be used as coverage for illnesses and injuries and that I am ultimately responsible for any costs incurred.
5. I agree to respect the rights, property and confidentiality of emergency workers and individuals affected by the disaster.
6. I agree to adhere to the rules/instructions of my job assignment(s) so as not to jeopardize relief operations or procedures.
7. I agree to uphold the mission of the health agency in the event of a disaster.

______

Signature Date

E.M.A. Oath Requirement

Each Vermilion County Medical Reserve Corps applicant is obligated to read and sign the oath of the Vermilion County Emergency Management Agency (E.M.A.) The purpose of such oath is designed to protect the integrity of the laws established by the Constitution of the United States and that of the State of Illinois; in addition, agreeing upon not to individually or in part to overthrow the Government of the United States by any means.

Oath required of E.M.A. Personnel

I, ______, do solemnly swear (or affirm) that I will support and defend and bear true faith and allegiance to the Constitution of the United States and Constitution of the State of Illinois and territory, institutions, and facilities thereof, both public and private, against all enemies, foreign and domestic that I take this obligation freely, without any mental reservation or purpose of evasion and that I will well and faithfully discharge duties upon which I am about to enter. And I do further swear (or affirm) that I do not advocate, nor am I nor have I been a member of any political party or organization that advocates the overthrow of the government of the United States or of this State by force or violence; and that during such time as I am affiliated with the Vermilion County Emergency Management Agency. I will not advocate, nor become a member of any political party or organization that advocates the overthrow of the government of the United States, or of this State by force or violence.

______

SignaturePrinted Name Date

______(____)______

Street AddressCityStateZip Code Phone Number

Please Send Completed Application to:Vermilion County Health Department

Attn: Melissa Rome

200 S. College St. Suite A

Danville, IL 61832

Email:

Fax: 217-431-7483

OFFICE USE ONLY

Date Accepted______EMA Director______

Date Accepted______MRC Coordinator______

4/2011

T:\Melissa's File\Emergency Preparedness\MRC\Medical Reserve Corps Application.doc