The Eagles Wings Foundation - Active Community Team

PATHFINDER VOLUNTEER ENROLLMENT FORM

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

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

Certifications/Licenses
(List each certificate/license along with expiration date – Eagles Wings 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
Can Lift 20lbs. __ Can Lift 50lbs. __ Can Walk 1 Mile __ Can walk 3-5 miles with a break

Allergies: _______________________________________ 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: I mmediate Disaster Response: ____ 1-2 Days Only ____ 1 Week Only ____ 2 Weeks ____ 2+ Weeks

Regular Office/Support Help in PBC? ____ Yes ____ No 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 ___________________________ and his/her Parent or Guardian ____________________________, 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, 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.). ___________________________ and ____________________________(Parent/Guardian) 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 ___________________________ , 20 ___ .

*______	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: For applicants under the age of 18, a parent or legal guardian is required to sign this release on behalf of the minor listed above. Minors that volunteer must have adult supervision with them and the minor to supervisor ratio can be no greater than "7 to 1". Minors and their supervisors MUST follow the direction of the Pathfinders command and may not deploy without authorization. All participants must bring with them enough food and water for 3 full days. When faxing this signed form in to EWF, you must send a photo government ID matching the Parent or Guardian’s signature. Further, in case emergency medical treatment is required on the minor listed above, I hereby give my permission to the physician selected by Pathfinders to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my child. I acknowledge I have read and understand this Emergency Authorization and give my full consent to the terms found herein. Further, I agree to all the Release terms spelled out above. I give my permission for the minor above to work in disaster areas both in and out of state, knowing this can be in a hazardous environment. If I have any restrictions on such a deployment, I check this box ___ and have attached an addendum which will be faxed with this form:

Signature: ___________________________________________ Printed name: __________________________________

Relationship to applicant: ___________________________ Type of ID Provided________________

FAX THIS SIGNED FORM to: 561-689-3534.