PATHFINDER VOLUNTEER ENROLLMENT FORM

THE EAGLES WINGS FOUNDATION, INC.
aka PATHFINDERS
375 Possum Pass
West Palm Beach, Florida 33413


Thursday, July 29th, 2010

YOUR PERSONAL INFORMATION:
* Red asterisks mark required fields
* First Name:
Birth Date:
* Last Name:
Employer/School:
* Address:
Emergency Contact Name:

* City:
Relationship:
* State:
* Zip Code:
Emergency Telephone:
* Telephone:
Drivers License #:
Evening:
DL Issuing Jurisdiction:
Cell:
DL Expiration Date:
Fax:
Other Equipment
Operation Skills?
* Email:
Your Vehicle(s) Type/Weight or People Capacity:

       #1 /        Willing to Transport?

       #2 /
Do you have your current vehicle registration in your vehicle now?  
Your Vehicle Liability Coverage: Are You Insured?  
Insurance Company:
Limit of Liability Insurance:
Your Education:

Your Certifications/Licenses
(Check each certificate/license you hold – The Eagles Wings Foundation will require a copy of any licenses for our records to verify any such credentials. Please email us copies of your certificates or if in a deployment, please bring copies with you.)

IS 100 IS 700 First Aid RN
IS 200 IS 800 EMT RNA
IS 300 IS 800B PM Haz Mat
IS 400 CERT PA Fire
IS 317 CPR DR Vol. Fire
Other Certifications/Licenses:
Your Health:
Do You Have Great Health? Yes No
 I have had a tetanus booster in the last 3 years: Yes No
I Have These Allergies: 
I Regularly Take These Medications: 
I Can Deploy to a Disaster Area Where Living Conditions Can Be Rugged
* I Agree to a Random Drug Test, if so required, for the Use of Any Illegal Drugs, Including Alcohol
Language Skills:
Native language:
Do you have an Amateur Radio License?

YOUR AVAILABILITY:
Immediate Disaster Response:
Regular Office/Support Help in PBC?
Can you respond out of area with no notice?
Where I Can Serve:
Are you willing to fly:

Disaster Recovery Related Career/Volunteer Experience:


Disaster Recovery Related Talents, Languages, Skills, and/or Hobbies:

Please note:  You are required to update this form at least one time per year between January 1 and May 1.  Working in hazardous environments requires the most up to date information we can secure from you.

THE EAGLES WINGS FOUNDATION, INC.
Pathifnder Task Force
375 Possum Pass
West Palm Beach, Florida 33413

Volunteer Agreement

Upon my request, this entire document can be read to me in either English or my native language, and can be explained in simple terms as well. By signing below, I authorize The Eagles Wings Foundation, Inc. to verify information in this application, and to perform a check of my background, including a criminal background check, as it applies to the volunteer jobs which I have expressed an interest in. I have no objection to having my record cleared through appropriate law enforcement agencies. I understand that all such information collected during the check will be kept confidential.

KNOW ALL MEN BY THESE PRESENTS: That , the first party, for and in consideration of other good and valuable consideration received from or on behalf of The Eagles Wings Foundation, Inc., and/or any agents of The Eagles Wings Foundation, Inc., including Scott Lewis, Carol Lewis, Disaster Solutions LLC, Pathfinder Task Force, and Scott Lewis' Gardening & Trimming Inc., party of the second part, the receipt whereof is hereby acknowledged (Wherever used herein, the terms "first party" and "second party" shall include singular and plural, heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, wherever the context so admits or requires.).


I hereby remise, release, acquit, satisfy and forever discharge the said second party, of and from all, in all manner of action and actions, cause and causes of action, suits, debts, dues, sums of money, accounts, reckonings, bonds, bills, specialties, covenants, contracts, controversies, agreements, promises, variances, trespasses, damages, judgments, executions, claims and demands whatsoever, in law or in equity, which said first party ever had, now had, or which any personal representative, successor, heir or assign of said first party, hereafter can, shall or may have, against said second party, for, upon or by reason of any matter, cause or thing whatsoever, from the beginning of the world to the day of these presents.

In addition, although Eagles Wings Foundation is a multi-faith-based organization, I understand that I am not allowed to promote any personal or group religious views while working under the Eagles Wings banner, and that discriminatory practices are prohibited. I commit to remaining sensitive to survivors’ needs and rights in seeking out their own personal faith needs. I also understand that any information I may gather as part of this team will be kept in the strictest of confidence.

I understand that if I am used in a deployment, Pathfinders operates under a paramilitary structure, and hereby agree to follow and support the chain of command in place at the time of the response. I also will place my personal safety, and the safety of all other volunteers, as a constant priority above all other issues. I acknowledge that if I am deployed in an actual disaster that I will be encountering and working within hazardous environments, and have volunteered of my own free will to do the same, fully understanding the inherent risks therein. I understand the importance of checking in and out with my supervisor. Finally, if I hold any state licenses or permits, I agree that I will not exceed the authority granted under such licenses in my duties while volunteering under Eagles Wings.

I hereby verify that I have read the entire Volunteer Handbook of The Eagles Wings Foundation, Inc., found on The Eagles Wings Foundation's website, and hereby agree to abide by all of the policies listed therein. Further, I have had the opportunity to ask questions in regards to these policies, and if English is not my native language, or if I have any difficulty reading any policy, have had the policies explained and/or translated to me in adequate detail so that I am comfortable in verifying that I can abide by all of the policies listed.

By my signature, I certify that all information contained herein is accurate and truthful, and understand what I am signing.

* Signature: Date:

* Witness Signature:

Click Here for a Printable Version of the Volunteer Enrollment Form

    
 
 
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