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First Name * This Field is Required Last Name * This Field is Required Street Address City State Zip Code Birthday Cell Phone * This Field is Required Home Phone Email * This Field is Required Drivers License # Emergency Contact #1 - Please include name and phone number * This Field is Required Emergency Contact #2 - Please include name and phone number * This Field is Required Shirt Size * This Field is Required Membership Prerequsites Are you willing to participate in a volunteer organization that is operated under business management principles and an established chain of command? * Yes No Are you willing to participate in ongoing training sessions throughout the year? * Yes No Do you own or are you willing to acquire a text capable cell phone for dispatch info? * Yes No Are you willing to submit required information for a background check facilitated by a third party? * Yes No MDR uniform and personal gear requirements could amount to an initial purchase of at least $200. Will you be able to comply with these requirements prior to your first deployment? * Yes No If the answer is no to any of the questions above, please explain: * This Field is Required Code of Conduct Are you willing to comply with the Code of Conduct? * Yes No Background Information Please list any other organizations or associations with which you are currently affiliated: (please spell out acronyms) Name: Role: Active Since: (DATE) Please list Skills, Training and/or Certifications RELATED to Disaster Response: (Please include dates and spell out acronyms) Description: Since: Please list UNRELATED Skills, Training and/or Certifications that you would like us to know about: (Please include dates and spell out acronyms) Description: Since: Have you ever been convicted of or pleaded no contest to any violation of the law other than minor traffic tickets? * Yes No Personal Declarations Do you know of anything physical, mental or otherwise, that would disqualify you from discharging your duties to this team or potentially cause harm to other members or victims in the field? * Yes No If the answer is yes, please explain. Are you willing to commit yourself to this team, work to the best of your ability to harmonize with the other members, and to the best of your ability foster a positive attitude? * Yes No Please explain: Do you fully understand and agree that your acceptance and continued membership on this team is “at will” and can be terminated for any code of conduct violations, failure to perform, or any other disruptive behavior or attitude as determined by Executive Leadership team or Board? * Yes No Please explain: Please state why you feel you would like to serve in this organization and what you expect to contribute to and obtain from the this organization. * This Field is Required I authorize Minuteman Disaster Response (MDR) to conduct an investigation of all information contained in this application for membership, and I release from all liability Minuteman Disaster Response and all companies and corporations supplying such information. I understand that any false answers, statements or implications made by me shall be considered sufficient cause for discharge. I hereby agree to submit to any drug test or criminal background screening that may be required. During my membership period, I understand and agree that if I receive medical treatment for a physical, psychological, emotional, or psychiatric condition that may impact my membership, or am involved in any criminal offenseI will notify the Executive Director. I understand that by applying to MDR, I am acknowledging and agreeing to abide by all elements of the Code of Conduct as written. Furthermore, by applying to MDR, I acknowledge and agree that failure to abide by any of the elements of the Code of Conduct, whether in fact or in spirit, will be grounds for immediate dismissal from the organization. I have read and understand the above. First Name * This Field is Required Last Name * This Field is Required Street Address City State Zip Code Birthday Cell Phone * This Field is Required Home Phone Email * This Field is Required Drivers License # Emergency Contact #1 - Please include name and phone number * This Field is Required Emergency Contact #2 - Please include name and phone number * This Field is Required Shirt Size * This Field is Required Membership Prerequsites Are you willing to participate in a volunteer organization that is operated under business management principles and an established chain of command? * Yes No Are you willing to participate in ongoing training sessions throughout the year? * Yes No Do you own or are you willing to acquire a text capable cell phone for dispatch info? * Yes No Are you willing to submit required information for a background check facilitated by a third party? * Yes No MDR uniform and personal gear requirements could amount to an initial purchase of at least $200. Will you be able to comply with these requirements prior to your first deployment? * Yes No If the answer is no to any of the questions above, please explain: * This Field is Required Code of Conduct Are you willing to comply with the Code of Conduct? * Yes No Background Information Please list any other organizations or associations with which you are currently affiliated: (please spell out acronyms) Name: Role: Active Since: (DATE) Please list Skills, Training and/or Certifications RELATED to Disaster Response: (Please include dates and spell out acronyms) Description: Since: Please list UNRELATED Skills, Training and/or Certifications that you would like us to know about: (Please include dates and spell out acronyms) Description: Since: Have you ever been convicted of or pleaded no contest to any violation of the law other than minor traffic tickets? * Yes No Personal Declarations Do you know of anything physical, mental or otherwise, that would disqualify you from discharging your duties to this team or potentially cause harm to other members or victims in the field? * Yes No If the answer is yes, please explain. Are you willing to commit yourself to this team, work to the best of your ability to harmonize with the other members, and to the best of your ability foster a positive attitude? * Yes No Please explain: Do you fully understand and agree that your acceptance and continued membership on this team is “at will” and can be terminated for any code of conduct violations, failure to perform, or any other disruptive behavior or attitude as determined by Executive Leadership team or Board? * Yes No Please explain: Please state why you feel you would like to serve in this organization and what you expect to contribute to and obtain from the this organization. * This Field is Required I authorize Minuteman Disaster Response (MDR) to conduct an investigation of all information contained in this application for membership, and I release from all liability Minuteman Disaster Response and all companies and corporations supplying such information. I understand that any false answers, statements or implications made by me shall be considered sufficient cause for discharge. I hereby agree to submit to any drug test or criminal background screening that may be required. During my membership period, I understand and agree that if I receive medical treatment for a physical, psychological, emotional, or psychiatric condition that may impact my membership, or am involved in any criminal offenseI will notify the Executive Director. I understand that by applying to MDR, I am acknowledging and agreeing to abide by all elements of the Code of Conduct as written. Furthermore, by applying to MDR, I acknowledge and agree that failure to abide by any of the elements of the Code of Conduct, whether in fact or in spirit, will be grounds for immediate dismissal from the organization. I have read and understand the above.
