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First Name: |
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Last Name: |
________________________ | Employer/School: |
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Address: |
________________________ | Emergency Contact Name: |
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City: |
________________________ | Relationship: |
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State: |
Zip Code: | Emergency Telephone: |
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Telephone: |
________________________ | Drivers License #:
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Evening: |
________________________ | DL
Issuing Jurisdiction: |
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Cell: |
DL Expiration Date: |
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Fax: |
________________________ | Other Equipment Operation Skills? |
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Email: |
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| Your Vehicle(s) Type/Weight or People Capacity: #1 / Willing to Transport? #2 / |
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| Do you have your current vehicle registration in your vehicle now? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Your Vehicle Liability Coverage: Are You Insured? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Limit of Liability Insurance:
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| Your Education: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Your Health: Do You Have Great Health? ___Yes ___ No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Allergies: _______________________________________ 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: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| YOUR AVAILABILITY: I mmediate Disaster Response: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Regular Office/Support Help in PBC? Respond out of area with no notice? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Where I Can Serve: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Are you willing to fly: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Disaster Recovery Related Career/Volunteer Experience: |
_____________________________________________________________ _____________________________________________________________ |
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Disaster Recovery Related Talents, Languages, Skills, and/or Hobbies: |
_____________________________________________________________ _____________________________________________________________ |
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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.Pathfinder Task Force 375 Possum Pass West Palm Beach, Florida 33413 Volunteer Agreement |
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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.). 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. |
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FAX THIS SIGNED FORM to: 561-689-3534.
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