Registration: Rock Medicine a program of healthRight 360 (Shiftboard)


 All medical volunteers must have ONE of the following:

  • AHA Healthcare Provider CPR card
  • Red Cross Professional Rescuer CPR card
  • ASHI CPR Pro for the Professional Rescuer card

PLEASE NOTE: Your CPR card must be one of the 3 listed to be accepted and must be current. Some places offer cards that "comply with" or are "based off of" AHA ECC Guidelines. These are NO LONGER accepted. Your card MUST be ISSUED by one of the above agencies AND be for healthcare providers. See below for exceptions.

We understand that some workplaces, including hospitals, issue their own Healthcare Provider CPR cards in lieu of one from one of the organizations previously listed. If this is the case, please describe your situation in the comment box at the end of this page.

The maximum upload for all files are 4MB.

* required field

* Gender
* Date of Birth
* Do you text?
 Yes  No
How did you hear about us/who referred you to us?
* Are you UNDER 18 years of age?
 Yes  No
* Have you ever volunteered with or worked for Rock Medicine, HealthRIGHT360 or its affiliates before?
 Yes  No
If yes, where and when?
* Have you ever been convicted of a felony?
 Yes  No
(Felony question) If yes, please explain.
* Have you ever been sued for malpractice?
 Yes  No
(Malpractice question) If yes, please explain.
* T-Shirt Size

Emergency Contact
* Emergency Contact Name
* Emergency Contact Relationship
* Emergency Contact Phone

Work Experience
* Current Employer
How long?

Volunteer Experience
Previous volunteer experience - duties
Location/Dates/Contact Person
Previous volunteer experience - duties (2)
Location/Dates/Contact Person (2)

* Name of school
* School Address
* Course of study
* Years completed
* Date of completion
Describe any specialized training, apprenticeship, skills and extra-curricular activities that may be beneficial. Please note any languages you can speak, read and/or write other than English and how fluent you are.

Professional Licenses/Certifications
* Do you have a current CPR for the Healthcare Provider card?
 Yes  No
* CPR card expires on
ACLS Certification Expiration Date
* Primary License/Certification Type
* Primary License/Certification Number
* Primary License/Certification Expiration Date
Please upload copies of your license(s) at the top of the page.
Second License/Certification Type
Second License/Certification Number
Second License/Certification Expiration Date
Third License/Certification Type
Third License/Certification Number
Third License/Certification Expiration Date
License/Certification Comments

* First Reference Name
* First Reference Business Relationship
* First Reference Phone
* Second Reference Name
* Second Reference Business Relationship
* Second Reference Phone
* Third Reference Name
* Third Reference Business Relationship
* Third Reference Phone



Note: Rock Medicine is a program of HealthRIGHT 360.


You may not use, possess, distribute, dispense, sell, or manufacture alcohol or illegal drugs while on HealthRIGHT 360 premises or while conducting HealthRIGHT 360 business. In addition, you may not be under the influence of alcohol, illegal drugs or prescription drugs being used illegally while on HealthRIGHT 360 premises or conducting HealthRIGHT 360 business. "Under the influence" as used here means any measurable amount of drugs or alcohol present in your system.


As a condition of volunteering with HealthRIGHT 360, I agree to abide by the terms of this statement.

* Drug Free Workplace Agreement electronically signed by:
* Drug Free Workplace Agreement Signed on
* Employee/Volunteer Agreement Electronically Signed By
Refer to: Employee/Volunteer Agreement
* Employee/Volunteer Agreement Signed On
Abuse Reporting Responsibilities
* Abuse Reporting Responsibilities electronically signed by:
Refer to: Abuse Reporting Responsibilities Document
* Abuse Reporting Responsibilities signed on
Applicant's Statement
* Applicant's Statement electronically signed by:
Refer to: Applicant's Statement Document
* Applicant's Statement signed on
Enter your name and date. This will signify that you read, understand and agree.
Refer to: Code of Conduct

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Thank you for your interest!


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