• Medical Reserve Corps Volunteer Application

    Medical Reserve Corps Volunteer Application

  • Thank you for your interest in joining the TriCounty Health Department Medical Reserve Corp (Unit 308). If you have any questions or concerns, contact our MRC Coordinator, Kori Tipton, at ktipton@tricountyhealthut.gov or 435-247-1158. 

  • Contact Information

  • Professional Information

  • Volunteer Acknowledgments & Waiver

    As a condition of volunteering, I give TriCounty Health Medical Reserve Corps permission to conduct a thorough background check on me, which may include a review of sex offender registries, criminal history records and law enforcement records. I give TriCounty Health Medical Reserve Corps permission to inquire into my educational background, references, licenses, and employment and/or volunteer history. I also give permission to the holder of any such information to release it to TriCounty Health Medical Reserve Corps. I understand that all volunteer positions are conditioned upon favorable background information. 

    I understand that TriCounty Health Medical Reserve Corps is not obligated to provide me with a volunteer placement. I also understand that I am not obligated to accept the volunteer positions offered. 

    As a volunteer, I agree to be subject to the policies and procedures of TriCounty Health Medical Reserve Corps. 

    I understand that TriCounty Health Medical Reserve Corps reserves the right to terminate my volunteer status at any time. 

    I hold TriCounty Health Medical Reserve Corps harmless of any liability, criminal or civil, that may arise as a result of the release of this information about me. I also hold harmless any individual or organization that provides information to TriCounty Health Medical Reserve Corps. I understand they will use this information only as part of its verification of my volunteer application. 

    I verify by my signature below that the above information is accurate to the best of my knowledge, and I have read each of the above items and agree to be bound by them.

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  • Volunteer Code of Conduct

    • As a volunteer, I will treat everyone with respect, patience, integrity, courtesy and dignity. 
    • While volunteering, I will not use profanity, or make humiliating, ridiculing, threatening or degrading statements. 
    • As a volunteer, I will strictly observe all safety rules and use care in the performance of my assigned tasks. 
    • As a volunteer, I will perform only those assigned tasks that are within my physical capability; and will not undertake any tasks that are beyond my physical capability or ability. 
    • As a volunteer, I will not undertake to operate or use vehicles, equipment or tools that I am unfamiliar with or have not been trained to operate properly and safely, and have not received specific authorization to use from my supervisor. 
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  • Confidentiality & HIPPA

    Due to the nature of services that the Medical Reserve Corps (MRC) provides, you may process information that is confidential and not public record.  For that reason you are asked to sign a confidentiality statement 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, hereby certify that I have read the statements above and below and agree to comply with the terms. 

    I realize that as a TriCounty Health Medical Reserve Corps member, 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. 

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  • Photography Consent 

    The TriCounty Health Medical Reserve Corps frequently takes photographs of volunteers in action during training, exercise, and actual events. In addition, each volunteer is photographed for identification purposes. Photographs may be used on the website, in newsletters, and other publications.  

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  • Authorization for Background Checks

    I authorize the company to obtain my background report, including investigative consumer reports. I also agree that a copy of this form is valid like the signed original. I understand that, as allowed by law, the company may rely on this authorization to order additional background reports, including investigative consumer reports. (1) during my time as a volunteer and (2) from companies other than ADP Screening and Selection Services without asking me for my authorization again, as allowed by law. I understand the company may order a background report under my legal name and any other names I may have used.


    I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, as allowed by law. Including but not limited to: my past or present employers; learning institutions; including colleges and universities; law enforcement and all other federal , state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker’s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes but is not limited to, military service, professional credentials and licenses and substance abuse testing.

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