Membership Application - Minuteman Disaster Response

First Name * This Field is Required

Last Name * This Field is Required

Street Address * This Field is Required

City* This Field is Required

State* This Field is Required

County/Parish

Zip Code* This Field is Required

Gender*

This Field is Required

Birthday *

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Phone * This Field is Required Please give a valid phone number.

Email * This Field is Required.

Emergency Contact Phone * This Field is Required

Shirt Size* This Field is Required

Medication Allergies

Upload Profile Picture* This Field is Required

Please use a photo with a blank background and only one subject in frame. This photo is used for your MDR ID Badge

Membership Prerequsites

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

Background Information

Please list any organizations and skills, related or unrelated, that pertain to Disaster Relief

Personal Declarations

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:

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

How Did You Hear About Us? 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.

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