GO Health VALOR MRC Application

Thank you for your interest in being an ACTIVE MRC member!

ACTIVE membership requires:

Completion of this application
Creating a ServNY account
Completing 2 online trainings (ICS 100 and psychological first aid)
Attending an in-person refresher/orientation session at least once every 3 years.

A GO Health VALOR MRC photo ID badge will be issued once you first become active. Past participants in good standing are LEGACY members. Thank you for your service!

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* 1. Full Name with any degrees:

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* 2. Preferred Emails (please include all e-mails you would like to receive MRC alerts or notices on):

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* 3. Preferred Phone Number:

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* 4. Is this number a cell phone number?

Yes

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* 5. Optional Alternate Phone Number

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* 6. Is this number a cell phone number?

Yes

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* 7. Current occupation or title (for retired put "retired"):

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* 8. **Date of birth (mm/dd/yyyy):**

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* 9. Any Agency Affiliations:

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* 10. Home Address (Street, City/Town/Village, State, Zip code)

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* 11. Mailing Address (if different from above)

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* 12. Which county(ies) would you like to volunteer in?

Genesee

Orleans

Both

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* 13. Emergency Contact Information
In emergency, notify:

Name

Relationship

Phone

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* 14. Volunteer Agreements and Consents:

I verify that I have not been convicted of a felony. I further verify that within the last 5 years, I have not been convicted of a misdemeanor that resulted in imprisonment. If I HAVE, I will submit a separate explanation with this application detailing the circumstances. If these statements are incomplete or untrue, I understand my volunteer assignment will be terminated.

I understand that GO Health and affiliated agencies reserve the right to perform driver’s license, reference, Medicaid/Medicare exclusion screening, police record, or criminal background checks.

I understand that photos taken of me while volunteering may be used for publicity purposes, including social media. I grant GO Health, including either Genesee or Orleans County Health Departments, permission to use my likeness in a photograph in any and all publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of GO Health and will not be returned. However, should I for any reason object to a specific image of me being used for publicity or social media, I will submit a written request for removal to the Unit Leader or Deputy Leader, and anticipate removal of the image on platforms maintained by GO Health at the discretion of GO Health.

I consent to be included on the GO Health VALOR MRC listserve, as well as to receive communications and alerts through other means related to my volunteer interests. I may withdraw my listserve participation at any time.

By signing/typing my name below, I agree to the statements above

Experience: Please give a short description as appropriate.

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* 15. Any past medical, healthcare, public health, or social service related experience?

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* 16. Any current licensures related to the experience above? Please provide professional license type, state-issued & ID number, and expiration date.

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* 17. Any other professional experience related to community service?

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* 18. Any particular areas of interest related to community service?

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* 19. Skills & Training: Please check wherever you have professional skills with training, please only check if training is current.

First Aid (check only if current)

CPR (check only if current)

AED (check only if current)

Data Entry

CB Radio

Ham Radio

Driving / Transportation

Traffic Control

Search & Rescue

Construction

Food Preparation

Child Care

Chaplain / Pastoral Care

Firefighting

Law Enforcement

Mental Health

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* 20. Potential Interests: Please check the activities for which you would like to receive further information and communication.

Free preparedness safety trainings (CPR, First-Aid, Narcan, etc.)

Volunteer service for Health Department rabies clinics (Any of the scheduled 4-5 clinics each year per county for cats, dogs, and ferrets)

Volunteer service to support emergency response efforts (Such as outreach and clinics for infectious disease testing or immunizations)

Community service projects coordinated by the Health Department (TBD)

Other service projects coordinated by established MRC partner agencies (As needed)

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* 21. Do you have any allergies or sensitivities we should know about?

Yes

Please specify:

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* 22. Do you have any disabilities or access and functional needs that we could help accomodate?

Yes

Please describe:

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* 23. Do you have any experience helping others with disabilities or access and functional needs?

Walking limitation assistance

Wheelchair assistance

Wheelchair transport

Dementia Assistance

Other cognitive ability assistance

Hygiene assistance

Other:

Other (please specify)

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* 24. Are you proficient in any non-English languages (including sign language):

	Fluent	Professional use	Working use	Basic
1st	1st Fluent	1st Professional use	1st Working use	1st Basic
Please specify language:
2nd	2nd Fluent	2nd Professional use	2nd Working use	2nd Basic
Please specify language:
3rd	3rd Fluent	3rd Professional use	3rd Working use	3rd Basic
Please specify language:
4th	4th Fluent	4th Professional use	4th Working use	4th Basic
Please specify language:

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* 25. Between the following 3 categories, how would you rank your personal activity level?

Low: Does not involve routine and extended periods of walking or other similar activity.

Moderate: Involves routine and extended periods of walking, pushing or pulling objects less than 75 lbs., carrying objects less than 50 lbs., use of stairs, and tasks involving moderate effort with considerable use of arms, legs, or occasional total body movements.

Vigorous: Involves routine and extended periods of running, rapid movement, pushing or pulling objects more than 75 lbs., lifting objects of 50 lbs., or more, or other tasks involving strenuous effort and extensive body movement.

Low

Moderate

Vigorous

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* 26. What is your preferred size for MRC t-shirts, jackets, or identification vests?

Small

Medium

Large

XXL

XXXL

Final steps:
1) If you have not done so already, create a ServNY account at https://apps.health.ny.gov/pub/servny/
2) Complete the trainings for Incident Command System (ICS 100) and Introduction to Psychological First Aid (PFA), either online or at one of our in-person refresher/orientation sessions.
3) See more information along with our annual schedule of training events at our website https://gohealthny.org/phep
4) Please email any completed course certificates to both david.bell@co.genesee.ny.us & cora.young@orleanscountyny.gov
along with copies of any relevant licenses or certifications.
5) Click the 'Done' button to submit your application.

We look forward to seeing you at any of our upcoming refresher/orientation sessions so that you can better get to know us and our goals, as well as review our MRC Policy Handbook! A digital photo will also be needed at this time so that we can prepare your MRC ID badge. We look forward to getting to know you better, and to working with you!

Sincerely,
David Bell, MRC Unit Leader
Cora Young, MRC Deputy Unit Leader

GO Health VALOR MRC Application

Thank you for your interest in being an ACTIVE MRC member!

Question Title

* 1. Full Name with any degrees:

Question Title

* 2. Preferred Emails (please include all e-mails you would like to receive MRC alerts or notices on):

Question Title

* 3. Preferred Phone Number:

Question Title

* 4. Is this number a cell phone number?

Question Title

* 5. Optional Alternate Phone Number

Question Title

* 6. Is this number a cell phone number?

Question Title

* 7. Current occupation or title (for retired put "retired"):

Question Title

* 8. Date of birth (mm/dd/yyyy):

Question Title

* 9. Any Agency Affiliations:

Question Title

* 10. Home Address (Street, City/Town/Village, State, Zip code)

Question Title

* 11. Mailing Address (if different from above)

Question Title

* 12. Which county(ies) would you like to volunteer in?

Question Title

* 13. Emergency Contact Information In emergency, notify:

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* 15. Any past medical, healthcare, public health, or social service related experience?

Question Title

* 16. Any current licensures related to the experience above? Please provide professional license type, state-issued & ID number, and expiration date.

Question Title

* 17. Any other professional experience related to community service?

Question Title

* 18. Any particular areas of interest related to community service?

Question Title

* 19. Skills & Training: Please check wherever you have professional skills with training, please only check if training is current.

Question Title

* 20. Potential Interests: Please check the activities for which you would like to receive further information and communication.

Question Title

* 21. Do you have any allergies or sensitivities we should know about?

Question Title

* 22. Do you have any disabilities or access and functional needs that we could help accomodate?

Question Title

* 23. Do you have any experience helping others with disabilities or access and functional needs?

Question Title

* 24. Are you proficient in any non-English languages (including sign language):

Question Title

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* 26. What is your preferred size for MRC t-shirts, jackets, or identification vests?

* 8. **Date of birth (mm/dd/yyyy):**

* 13. Emergency Contact Information
In emergency, notify: