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Join the MRC

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Medical Reserve Corps Application

The following information will be used only by appropriate authorities in your professional organization for notification in an emergency. If you agree to participate, it is our plan to input this data to the Utah Notification and Information System.

Medical Reserve Corps Application

Full Name

Date of Birth (mm/dd/yyyy, 05/15/1973)

Mailing Address

Mailing City

Mailing State

Mailing Zip Code (5 digit)

Physical Address

Physical City

Physical State

Physical Zip Code (5 digit)

24/7 Telephone (nnn-nnn-nnnn)

Cell Phone (nnn-nnn-nnnn)

Office Telephone (nnn-nnn-nnnn)

Home Telephone (nnn-nnn-nnnn)

Fax Number (nnn-nnn-nnnn)

E-mail Address

Confirm E-mail Address

Drivers License State

Drivers License Number

Date of Expiration (mm/dd/yyyy, 05/15/2050)

Professional Designation(s) / Degree(s)

It is understood that your availability will be contingent on your personal and professional responsibilities. Once your primary responsibilities are taken care of, where do you anticipate you will help your community? If your primary response site will be at one of the hospitals, long-term care facilities, or other pre-assigned location, please list them here.

Professional Responsibilities

We must have a copy of your drivers license to process your application. The first option is to attach a bmp, gif, or jpg (jpeg) file to this form when you submit it. This option allows us to process your application more quickly. You can browse and attach the file below. Otherwise, you must mail your photo to us at the following address: Millard County CERT Program, 765 South Hwy 99, Fillmore, UT 84631-5002.

Drivers License Upload

We appreciate your committment to volunteer with our organization.By typing your full name again below and submitting the form, you authorize Central Utah Public Health to obtain a background check to verify your eligibility. (Your name must exactly match the name you typed earlier.)

Confirm Your Full Name

Deputy Fox Fund

A memorial fund for Deputy Josie Fox has been set up. If you wish you may donate at any Zions Bank location under the name of Deputy Josie Fox.

Safe Tip

When on the phone, do not admit to a stranger that you are alone. Also, instruct your children, when alone, to say that Mom or Dad is busy and to ask the caller to leave a message or call back.