WEBER MORGAN MEDICAL RESERVE COPRS VOLUNTEER APPLICATION FOR TEMPORARY EMERGENCY VOLUNTEER MEMBERSHIP TO THE WEBER MORGAN MEDICAL RESERVE COPRS
The following volunteer application includes personal identification and contact information. This information is secure and will be used only to contact you about volunteer opportunities.
* Last Name: * First Name: Middle Initial:
*Address:
Example: 477 23rd Street -- Ogden, Utah 84401
* In which county do you reside?
License Number: Effective Date:
Example: 1-1-2009
Expiration Date:
Example: 1-1-2009
* Select one of the following: RN | LPN | Unlicensed | Other
* Primary Phone: Secondary Phone: Email:
Emergency Contact Information
* Primary Emergency Contact: * Relationship:
* 1st Phone #: Second Phone #: Email:
Please Read, (click the hyperlink to see the policy) and checked that you have read the WMMRC policies
* Completely read, understand and sign the "WMMRC HIPAA Policy"
* Completely read, understand and sign the "WMMRC Media Release Policy"
* Completely read, understand and sign the "WMMRC Volunteer Risk Policy"
* Completely read, understand and sign the "Volunteer Confidentiality Policy"
* Completely read, understand and sign the "Release of Confidential Policy"
* Completely read, understand and sign the "Volunteer Liability Protection Statement"
 
* Completely read and understand "Authorization to Conduct an Investigational Background Check" in the shaded box below. A satisfactory investigational background check is part of the requirment to become a member of Weber Morgan's Medical Reserve Corps.

AUTHORIZATION TO CONDUCT AN INVESTIGATIONAL BACKGROUND CHECK

I authorize the Weber County Sheriff’s Office to conduct an investigation into my background and share that information with the Weber-Morgan Health Department for the purpose of allowing me to enroll in the Weber-Morgan Medical Reserve Corps.
* Full Name: * Date:
* Utah Driver's License Number: * Date of Birth:
Example: 1-1-2009

WMHD is committed to protecting your security. Your files are kept in confidential and are only accessible to authorized personnel


If you are filling this application out a paper application, copies of the above policies and statements will be provided to you.

I have read the above mentioned policies. Furthermore, I understand that I may call the WMMRC Coordinator at 801-399-7100 and have any questions answered prior to signing them. By signing, I agree that I will abide by the above mentioned policies and procedures while acting in the capacity of a MRC volunteer for the Weber Morgan Medical Reserve Corps.


* Printed Name of Volunteer: * Electronic Signature: * Date:
Example: 1-1-2009
*Required Fields

Please note that this application form allows volunteers to become member of the Weber Morgan Medical Reserve Corps on a temporary basis. For full membership, go to the Utah Healthcare Volunteer Registry and apply on line. Be sure to indicate that you wish to be associated with the Weber Morgan Medical Reserve Corps.