Please check all trainings and/or skills you possess below.

It is anticipated that during some emergency operations, staff will be needed 24 hours per day.

It is expected that volunteers will be asked to work 8-12 hour shifts.

Persons volunteering for CERTS only or CERTS/MRC must participate in a 20 hours training.
The Classes will be on the weekends, weeknights or a combination of both. 

I understand that it is my responsibility to notify the City of Stamford of any circumstances that affect the accuracy of the information provided here.

Pursuant to Federal regulations, MRC members are required to undergo a criminal background check as part of the application process.

By signing below, I agree to allow the Stamford Citizen Services Corps to make any investigation of my personal history deemed necessary to verify the information above.

I attest that to the best of my knowledge, the information provided in this application is correct and accurate. I understand that this information will be contained in a secure database administered by the  Stamford Department of Health, and that it will be made available in an electronic format to the City of Stamford for the purposes of contacting me in case of a declared state of emergency, for training purposes, and/or a public health need.  Depending on need and availability, although I have volunteered, I understand that, I may not be called upon to volunteer in instances when volunteers are needed.

I understand that I retain the right to refuse to volunteer for any reason.  I understand that I will not receive compensation or payment for any services I render.  I further understand that I am not able to bill any individual, organization or business for services I render while acting in the capacity of a volunteer for the Stamford Medical Reserve Corps, or the Community Emergency Response Team.

I recognize that in my role as a City of Stamford Department of Health Medical Reserve Corps. (MRC) volunteer, I am obligated to adhere to the law as outlined under the health insurance portability and accountability act (HIPAA) and the family educational rights and privacy act (FERPA) and other applicable laws that protect privacy and confidentiality and provides for the security of information that I may have access to in my role as a MRC volunteer.

I further understand that privacy means the right of an individual to keep his or her education, personnel, and or health information private; confidentiality refers to the duty of anyone entrusted with education, personnel, and or health information to keep that information private; and security refers to the duty of persons entrusted with education, personnel and or health information to prevent unauthorized access to the information.

I also understand that the Stamford Department of Health is legally obligated to protect the privacy, confidentiality and security of the information it collects, and I have been advised that the Stamford Department of Health and the City of Stamford can take necessary action if a breach of confidentiality and or security occurs. I also understand that my adherence to this agreement applies throughout and subsequent to my agreement to serve as a MRC volunteer with the Stamford Department of Health.

I therefore pledge that I will NOT divulge information, obtained during any volunteer activities with the Stamford Department of Health to anyone other than to those who are approved to have access to the information. I also understand that the Stamford Department of Health is legally obligated to protect the privacy, confidentiality and security of the information it collects, and I have been advised that the Stamford Department of Health and the City of Stamford can take necessary action if a breach of confidentiality and or security occurs. I also understand that my adherence to this agreement applies throughout and subsequent to my agreement to serve as a MRC volunteer with the Stamford Department of Health.

I agree to protect all confidential information during its collections, use, storage, and destruction. Disclosure of confidential information will be done only with explicit instructions from MRC Unit Director.

THANK YOU FOR YOUR INTEREST IN VOLUNTEERING WITH THE STAMFORD CERT/MRC.
Please Submit completed application or Print and fax to the Stamford Citizen Services Corps

Stamford Citizen Services Corps
888 Washington Boulevard, 8th FL
Stamford, CT 06901
Phone: 203.977.4398
Fax: 203.977.5506
E-mail: StamfordCERTMRC@stamfordct.gov