Salt Lake County Medical Reserve Corps

Salt Lake County Medical Reserve Corps - Intake Form

Please complete all required sections of this form to apply for the SLCoMRC. If you have any questions, please contact us at MRC@saltlakecounty.gov.

Thank you!

Terms of Service and Privacy Policy

Smartsheet to Utah Responds Acknowledgement*

By applying for the Salt Lake County Medical Reserve Corps (SLCoMRC) using this Smartsheet form, I consent all data provided here will also be transferred to Utah Responds, which serves as the State of Utah's standard Volunteer Management System (VMS) for all other MRC units. SLCoMRC has opted to transition to an alternative system that serves our needs better. This transfer of information is essential to meet statewide operational requirements, facilitate cross-county deployments, and ensure efficient volunteer management across the State of Utah.

By checking this box, I indicate that I agree to the Terms of Service and have read and understand the Privacy Policy for this site. My submission of this form will constitute my consent to the collection and use of this information and the transfer of this information across the Internet to processing and storage facilities supporting this system. I also agree to receive required administrative and legal notices such as this electronically.

Information Pledge*

By checking this box, I pledge to provide only correct information when completing this registration process. I also give consent to Utah Responds and their designated agents to collect, use, verify, and maintain any information that is collected through the use of this site.

Background Check*

I hereby authorize Utah Responds and its designated representatives to investigate my background and qualifications for the purpose of determining whether I am qualified for the position(s), volunteer or employment, for which I am applying. This authorization will be effective on the date I create my profile in this electronic registry and will remain in effect until my account is terminated, in writing (via email or letter), by me or Utah Responds. I understand Utah Responds will conduct such background investigation with the assistance of one or more outside firms and the scope of this investigation will include, but not be limited to, employment history, education history, driver’s license records, public records of civil and criminal history, and professional licensing and credentialing. I understand that Utah Responds and its representatives will use the personal data entered by me into this electronic registry to conduct the background investigation. I certify that the information provided is, to the best of my knowledge, true and accurate. I further understand any mistakes or incorrect information in the personal data provided by me may affect the accuracy of any background investigation.

Conflict of Interest

Do you receive compensation as a result of a current contract with Salt Lake County?*

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If yes, please provide details*

Current Professional Status*

Licensed/Certified and Active - Please use then when your license is active and not expired at the time of sign up

Non-Licensed - Please use this if you do not have a license OR when your license is expired and or non active

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Are you an officer, director, agent, employee, or owner of a substantial interest in a business entity that is subject to the regulation of Salt Lake County or anticipates doing business with Salt Lake County?*

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If yes, please provide details*

Do you hold an investment, financial, or personal interest that creates a potential or actual conflict between your duties as a volunteer?*

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If yes, please provide details.*

Are you currently an employee of Salt Lake County?*

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Current SLC Employye

As you are currently an employee of Salt Lake County, you are not applicable to be a volunteer and can stop this application process.

Name and Address

First Name*

Middle Name

Last Name*

Address Line 1*

Address Line 2

City*

State*

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County*

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County - Other*

Zip*

Work State

Please add the state where you work

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Identifying Information

Social Security Number*

SSN is required to verify certain licensure information and for identification purposes. Smartsheet is HIPAA compliant.

Please enter SSN in "000-00-0000" format

Gender*

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Eye Color*

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Date of Birth*

Height Feet*

Height may be used in determining the sizes and types of personal protection equipment.

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Height Inches*

Height may be used in determining the sizes and types of personal protection equipment.

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Hair Color

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Contact Information

Email Address*

Confirm Email Address*

Please confirm that your email addresses above match and check the box.

Email Confirmation*

Preferred Contact Method*

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Mobile Phone*

Phone

Home Phone

Phone

Work Phone

Phone

Communication Preferences

Selecting Emergency, you will only receive volunteer deployments for emergency response.

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Occupation

What is your occupation type?*

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Medical*

Other

Non-Medical*

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Behavior Health*

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Public Health*

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Registration Feedback

Hear about site

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Comments

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