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Privacy Policy First Name * This Field is Required Last Name * This Field is Required Street Address City State --Please Select State-- Alabama (AL) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District Of Columbia (DC) Florida (FL) Georgia (GA) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) County * This Field is Required Zip Code Gender Please select oneMaleFemale Birthday Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birthday Cell Phone * This Field is Required Please give a valid phone number. Home Phone Email * This Field is Required Drivers License # Emergency Contact #1 & Phone * This Field is Required Emergency Contact #2 * This Field is Required Emergency Contact #2 & Phone * This Field is Required Emergency Contact #2 * This Field is Required Shirt Size Unknown S M L XL 2XL 3XL 4XL Blood Type Unknown O- O+ A- A+ B- B+ AB- AB+ Medication Allergies 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 This Field is Required Willing to Participate reason This Field is Required Are you willing to participate in ongoing training sessions throughout the year? * Yes No This Field is Required Willing to Attend training reason This Field is Required Do you own or are you willing to acquire a text capable cell phone for dispatch info? * Yes No This Field is Required Receive Text reason This Field is Required Are you willing to submit required information for a background check facilitated by a third party? * Yes No This Field is Required Background Check Reason This Field is Required 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 This Field is Required Please explain: This Field is Required 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 This Field is Required Legal reason This Field is Required 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 This Field is Required If the answer is yes, please explain. This Field is Required 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 This Field is Required Please explain: This Field is Required 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 This Field is Required Please explain: This Field is Required 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. Please fix the error(s) above You must be 18 years old to proceed this application