Pathfinder Volunteer Enrollment Form

PATHFINDER VOLUNTEER ENROLLMENT FORM

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

Monday, January 5th, 2009

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? Yes No

#2 / Do You Have Bus Availability? Yes No

Do you have your current vehicle registration in your vehicle now? Yes No

Your Vehicle Liability Coverage: Are You Insured? Yes No

Insurance Company:

Limit of Liability Insurance:

Your Education:
High School/GED 2yr Degree 4yr Degree Graduate Post-Graduate Other

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
Can Lift 20lbs. Can Lift 50lbs. Can Walk 1 Mile Can walk 3-5 miles with a break

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 Yes No

* I Agree to a Random Drug Test, if so required, for the Use of Any Illegal Drugs, Including Alcohol Yes No

Language Skills:
Native language: I can translate in:

YOUR AVAILABILITY:

Immediate Disaster Response: 1-2 Days Only 1 Week Only 2 Weeks 2+ Weeks

Regular Office/Support Help in PBC? Yes No

Can you respond out of area with no notice? Yes No

Where I Can Serve: In PBC Only In State of Florida In United States Foreign (have passport?)

Are you willing to fly: Commercial Only Private Plane Both

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.
aka PATHFINDERS
375 Possum Pass
West Palm Beach, Florida 33413
RELEASE AGREEMENT

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 in which I expressed an interest. 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.

*	GENERAL RELEASE: 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, Pathfinders’ 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.). 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 WITNESS WHEREOF, first party had hereunto set its hand and seal this day of , 200 .

*	In addition, although Eagles Wings Foundation is a multi-faith based organization, I understand that I am specifically not allowed to promote any personal or group religious views while working under the Eagles Wings banner. 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. 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.

*	By my signature below, I hereby verify that I have read through the entire policy and procedures manual of The Eagles Wings Foundation, Inc., (EWF) found on the EWF's web site 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.

	This entire document has been read to me in either English or my native language, and it has been explained in simple terms as well. I understand what I am signing.

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

* Signature: Date:

IMPORTANT: If you are under 18 years old , you must use the Printable Version ( see link below) and fax us your parental or guardian release rather than use this electronic signature.

Click Here for a Printable Version of the Volunteer Enrollment Form

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