AZ-ESAR-VHP:

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Volunteer Opportunities

Required field Join Active Statewide Response: As a volunteer to the "Arizona emergency system for advanced registration of volunteer health professionals" (AZ ESARVHP) join the State Medical Volunteers & Professionals Team (MVP team) and participate in active emergency response operations. Receive alerts on active incidents (e.g. COVID-19, Wildfire, etc.): All participation is voluntary - you can decline a call to service at any time.

Yes No

Required field Join Local Response Teams: As a volunteer you can affiliate with either the County/Tribe Public Health Department, Medical Reserve Corps (MRC), or other local teams serving the community. Volunteers have opportunities to serve in both no-emergencies and real world emergency events.

Yes No

Account Information

Creating an account is the first step in the Arizona Emergency System for Advance Registration of Volunteer Health Professionals registration process. You will use your account username and password each time you log into Arizona Emergency System for Advance Registration of Volunteer Health Professionals.

Username:

The username must be at least six (6) characters long and cannot contain spaces. Acceptable characters include alphanumeric (A-Z, 0-9) and the symbols @, ., -, and _. Usernames are not case sensitive.

Password:

Confirm Password:

Secret Question:

Secret Answer:

Terms of Service and Privacy Policy

Required field Terms of Service:

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.

Required field Information Pledge:

By checking this box, I pledge to provide only correct information when completing this registration process. I also give consent to Arizona Emergency System for Advance Registration of Volunteer Health Professionals and their designated agents to collect, use, verify, and maintain any information that is collected through the use of this site.

Required field Authorization:

I hereby authorize Arizona Emergency System for Advance Registration of Volunteer Health Professionals 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 Arizona Emergency System for Advance Registration of Volunteer Health Professionals. I understand Arizona Emergency System for Advance Registration of Volunteer Health Professionals 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 Arizona Emergency System for Advance Registration of Volunteer Health Professionals 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.

Name and Address

Prefix:

Example: Dr., Col., Mr., Mrs., Ms.

First Name:

Middle Name:

Last Name:

Suffix:

Example: Jr., Sr., MD., PhD, RN

Address Line 1:

Address Line 2:

City:

State:

County or Tribe of Residence:

County Tribe

If you are a tribal member, a tribal designee, or currently employed by a tribal government, please enter a Tribe of Residence.

County:

Zip Code:

Work State:

Alternate Address Line 1:

Alternate Address Line 2:

City:

State:

County:

Zip Code:

Identifying Information

Date of Birth:

Social Security Number:

SSN is used to verify certain licensure information and for identification purposes.

Contact Information

Primary Email Address

Delete

Email Address:

If you have an email account, it is important for you to provide this information. Without your email address, you may miss important messages and notifications. Please note that the system will not allow two accounts with the same email address. If you do not have an email address or your email address is already registered with the system, you can learn more about obtaining a free email address by clicking here.

Confirm Email Address:

Add Email Address

Contact Method 1

Delete

Contact Method 1:

Number to Attempt:

x

Pager Type:

Pager Carrier:

Pager ID/PIN:

Add Another Contact Method

Occupation Information

What is your occupation type?

Occupation:

If your occupation does not appear in the list, please select Other.

What is your current professional status for this occupation?

Arizona Emergency System for Advance Registration of Volunteer Health Professionals

Registration