Disaster Healthcare Volunteers

Quick Registration
The California Disaster Healthcare Volunteers website is operated by the California Emergency Medical
Services Authority and allows you to register as a volunteer willing to provide services during a disasteror emergency situation. This registration form will collect basic information about you. All informationthat you provide is held under the highest degree of care and standards ofsecurity, confidentiality and privacy.
Quick Registration Form

*Please Print ClearlyName__________________________________________________________________________
PrefixFirst Name

Last Name

SuffixAddress __________________________________________________________________________
Street Address

Apartment/Unit Number

Address ____________________________________________________________________City

Primary
Phone:County[ Please Circle One: Work Home Cell ] (StateZip Code) ____________________________________________
Area CodeAlternate
Phone:[ Please Circle One: Work Home Cell ] () ____________________________________________
Area Code

Email Address:

Birthdate ______ _____
MonthDay_____ Height _________ Hair Color ___________ Eye Color ___________
Year

Occupation: [ Please Circle One: Medical Non-Medical ] _______________________________________________
Professional
License Number: _____________________________ Expiration Date: ______ _____ _________
Veterinary Assistant Employer:MonthDayYear

Terms of Service and Privacy Policy
Terms of Service
By checking this box, I indicate that I agree to the terms of service and have read the Privacy policy. 1
My submission of this form will constitute my consent to the collection and use of this information andthe transfer of this information via the internet, by mail or fax to secure processing and storage facilities
supporting this system. I also agree to receive required administrative and legal notices such as thiselectronically.

Privacy Policy
By checking this box, I pledge to provide only correct information when completing this registration
process. I also give consent to California Disaster Healthcare Volunteers registry and its designatedagents to collect, use, check and maintain any information that is collected through the use of this site.
Signature: _______________________________________________________ Date: _____________________
Thank you for registering with Disaster Healthcare Volunteers. You will be receiving an email with your username
and temporary password. Once you receive the email, please log into www.healthcarevolunteers.ca.gov tocomplete your registration and make any needed corrections.

Privacy Policy for Disaster Healthcare Volunteers of California
Overview
The State of California Emergency Medical Services Authority (EMSA) is strongly committed to protecting theprivacy of registrants of the Disaster Healthcare Volunteers Site (Site) to the extent allowable under applicable
California law. EMSA wants to contribute to providing a safe and secure environment for our users.
The purpose of this Privacy Policy is to inform you, as a user of the Site or as a user of any Site content, whatkinds of information EMSA will gather about you when you visit the Site, how EMSA may use that information,
whether it can be disclosed to anyone, and the choices you have regarding EMSA's use of, and your ability torevise or update, that information. This Privacy Policy applies to the Site and any information collected through thisSite. This policy applies only to the Site and any information collected through this Site and not to any othercompanies' or organizations' Web sites to which this Site links.
Information About All Site Visitors
In general, this Site automatically gathers certain usage information, such as the number and frequency of visitors
to the Site. EMSA only uses such data in the aggregate. This aggregate data helps EMSA determine how muchcertain parts of the Site are used so that EMSA can improve the Site and assure that it is as appealing as it can befor as many users as possible. The Site uses a technology called "cookies" that tells EMSA how and when pages
in the Site are visited and by how many users. EMSA may partner with other organizations (such as professionalassociations) to recruit volunteers through those organization's websites. In such cases, EMSA may provide
aggregate statistical information to those partnering organizations to indicate how many volunteers were recruited
via partner websites. This reporting is entirely statistical (e.g., how many volunteers were recruited), not lists ofnames of specific volunteers solicited at a given partner's site. Most browsers are initially set up to accept"cookies." You can reset your browser to refuse all "cookies" or to indicate when a "cookie" is being sent.
Disclosure of Personal Information
When registering on the Site as a volunteer health professional in the Disaster Healthcare Volunteers System,volunteer registrants agree to provide certain personal identifying information and professional credentialing
information (collectively, Registration Information). EMSA collects, uses and maintains this Registration
Information in implementing the Disaster Healthcare Volunteers System. EMSA does not use the Registration
Information provided by volunteer registrants to the Site except to the extent described in the Site's Terms ofService. EMSA does not disclose any Registration Information provided by volunteer registrants to the Site except
to the extent that such disclosure is required pursuant to a California Public Records Act request (GovernmentCode sections 6250, et seq.) Disclosure of highly sensitive personal information will only be done in accordancewith the California Information Practices Act (Civil Code 1798.24), and any other relevant state or federal laws.
Additionally, as described above, EMSA may share aggregated statistical "ratings" information about the use ofthis Site with Web site partners.
Site Privacy Policy Changes
If changes are made to this Privacy Policy, EMSA will post those changes here so that users will be informed as towhat information is collected, how it is used and whether such information is disclosable.
Effective as of July 1, 2010