Region 4 Medical Reserve Corps (MRC) of Southwest Washington

Region 4 Medical Reserve Corps (MRC) of Southwest Washington

Thank you for your interest in joining our Medical Reserve Corps team!

There are a few steps and forms necessary in the application process which includes submission of the following application materials:

Completion of this application webform
Photo release form
Background check authorization
Additional paperwork to be collected as part of the onboarding process.

Completed forms can be emailed to us at region4mrc.ph@clark.wa.gov.

TIP: This form cannot be saved midway. Make sure you have the information handy prior to getting started.

If you have any questions, please contact us at 360.949.3169 or region4mrc.ph@clark.wa.gov

General information

First name*

Middle name*

Last name*

Preferred name (if different)

DOB*

Drivers license*

Pronouns

Select or enter value

What are your pronouns?

Blood Type

Select or enter value

Shirt size*

For your MRC t-shirt

Select

Why are you interested in joining the MRC?

Contact information

Primary phone*

Phone

Primary phone type*

Select or enter value

Secondary phone

Phone

Secondary phone type

Select or enter value

Primary email*

Secondary email

Home address

County of residence*

Select or enter value

Which county do you reside in?

Physical address*

City*

State*

Select or enter value

Zip*

Can you receive mail at this address?*

Select or enter value

Mailing address

Mailing address city

Mailing address state

Select or enter value

Mailing address zip

Employment information

Profession*

These fields are selected to correspond with our reporting categories with the national MRC program. Please select which is the closest match to your profession.

Select or enter value

Employer

Employer phone

Do you have a current medical or other license?

Select or enter value

License type

We are currently building our dropdown list based on our volunteer pool. Please select from the list or type in your response if your license is not listed.

Select or enter value

Licensure state

Select or enter value

License number

If you have licensures in more than one state, please enter both numbers in the box. Have your WA state license be listed as your primary response.

License expiration date

Experience and skills

Experience and skills to be added*

Please mark all that apply

Select or enter value

Do you have any FEMA certifications?

Yes

I don't know

Do you speak a language other than English?

Select or enter value

Language(s) spoken

Select or enter value

Language spoken not listed

Please provide the language you speak.

Emergency contact information

Who should we contact in case of an emergency?

Emergency contact name*

Relationship*

Select

Emergency contact phone*

Phone

Emergency contact email*

Volunteer safety - vaccine tracking

Ensuring the safety of our MRC volunteers is a top priority. To ensure you are protected during responses, the Region 4 MRC tracks the recommended vaccinations for healthcare workers.

Please provide to the best of your knowledge the year you received the following vaccines, had the disease, or obtained a positive titer test.

If you do not have verification of the following, it is recommended to check with your provider about the appropriateness of receiving the vaccine now. You may also request a laboratory test (also called a titer) from your provider to prove immunity.

In the event of an outbreak, you may be asked to provide proof of vaccination via medical records in order to respond.

Measles/mumps/rubella (MMR)*

Date/year received

Include the dates for both doses or titer date for all three

Varicella (Chickenpox)*

Date/year received

Include the dates for both doses or titer date

Tdap (Tetanus, Diphtheria, Pertussis)*

Date/year of most recent dose received

Influenza (flu)

Date/year received

Are you a medical professional?

Yes

Hepatitis B*

Date/year received

Include the dates for all three doses or titer date

Demographic information

To ensure our pool of volunteers reflect the communities we serve, efforts are being made to track general demographic information.

For consistency in reporting, Region 4 MRC unit is requesting the following demographic information. The following options reflect the US Census Bureau and the national MRC program reporting categories.

Race identity

Please select all that apply.

Select or enter value

Other race identity

Gender identity

Select or enter value

Send me a copy of my responses

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