here - Feed the Children

FEED THE CHILDREN
SHORT TERM TEAM APPLICATION
(Submit with non-refundable $75.00 application fee)
PERSONAL
(PLEASE PRINT)
Name (as it appears/ or will appear on your passport):
Other name (i.e. Nickname or name you casually go by):
Marital Status
_____Single
_____Engaged
_____Married
Age ______
Please list any skills, hobbies or interests you have:
Address:
City:
Phone: (
State:
)
Zip:
E-mail:
TRAVEL INFORMATION
Passport Number:
TSA Known Traveler Number (if any):
Date/Place of Issuance:
Date of Expiration:
Date of Birth:
Place of Birth:
Have you ever traveled outside the U.S. before? _____Yes _____No
If so, where:
Frequent Flier Number and Airlines:
CHILD SPONSORSHIP
Do you have a sponsored child in the community in which you will be visiting? _____Yes _____No
If yes, please list the child’s name, ID number, and country.
Child’s name:
ID #:
Country:
1
MEDICAL INFORMATION & PROFILE
Name: ______________________________________
MEDICAL INFORMATION: The following information will only be used in case of an emergency, medical or otherwise.
IN CASE OF EMERGENCY CONTACT: (Please verify that your contact is scheduled to be available during the dates of your trip)
Name
Address
City ___________________________State ____ Zip Code____________ E-mail ___________________________
Area Code & Telephone #
Relationship _______________________________________
Secondary Emergency Contact:
Name
Address
City ___________________________State ____ Zip Code____________ E-mail ___________________________
Area Code & Telephone #
Relationship _______________________________________
Insurance Company:
Date of last Tetanus shot:
1. Do you have any physical limitations?
Policy #:
Date of last Polio and MMR shot:
Blood Type:
_____Yes _____No
If yes, please explain:
2. Do you have any known allergies? _____Yes _____No
If yes, please explain:
3. Do you have any dietary restrictions or food allergies? _____Yes _____No
If yes, please explain:
4. Are you currently using any medications? _____Yes _____No
If yes, please explain:
5. Are you currently receiving medical treatment? _____Yes _____No
If yes, please explain:
2
Release and Waiver of Liability
PLEASE READ CAREFULLY!
THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS!
This Release and Waiver of Liability (the “Release”) executed on this
day of
, 20
, by
(the “Volunteer”) in favor of Feed the Children, Inc., a nonprofit corporation, their directors, officers,
employees, and agents (collectively, “FEED”).
The Volunteer hereby freely, voluntarily, and without duress executes this Release under the following terms:
1.
I have been and am informed by this document that any travel, volunteer work, or other activities I undertake in connection with FEED,
partnering agencies, organizations, or individuals presents inherent risk, including, but not limited to, loss of property, disease, illness,
injury, exposure, physical and mental harm, and death, which may be caused by, among other things, the elements, organisms,
environmental conditions, crime, accidents, negligence, and political conflict including civil war, war, and terrorism. (Initial ________)
2.
The undersigned recognizes and acknowledges that FEED is a charitable, non-profit corporation engaged in human services and relief
activities. The undersigned, for himself/herself and his/her heirs, does hereby freely and knowingly waive any and all actions, causes of
actions, claims, and demands for or by reason of loss of life, bodily injury, including, but not limited to the contraction of any endemic
diseases, costs, damage, or expense for any act or omission and/or negligence of any kind on the part of any third party, myself, and/or on
the part of FEED or any of its officers, agents, servants or employees for anything in any way arising from or connected with, either
directly or indirectly, any volunteer activities of the undersigned Volunteer or of FEED. The undersigned realizes that activities which
he/she intends to pursue may entail some amount of risk (as set forth above) or possible danger and desires to personally assume all such
risks and loss of any kind. (Initial ________)
3.
This agreement is intended to be as broad and inclusive as permitted by the laws of the State of Oklahoma. This agreement is to be
governed by the laws of the State of Oklahoma. If any portion of this agreement is held invalid, it is agreed that the remainder shall
nevertheless continue in full force and effect. (Initial ________)
4.
I hereby release and forever discharge FEED from any claim whatsoever that arises or may hereafter arise on account of any first-aid
treatment or other medical services rendered in connection with an emergency during my time with FEED. (Initial ________)
5.
I hereby expressly and specifically assume the risk of injury or harm during my time as a volunteer and release FEED from all liability for
injury, illness, death, or property damage resulting from the events/activities during my time as a volunteer. (Initial ________)
6.
I have been advised that FEED maintains a DRUG FREE WORK AREA and that no person is allowed on FEED property or allowed to
work if he or she is under the influence of alcohol and/or drugs. I agree to abide by this drug free policy during any time I am a volunteer.
(Initial ________)
7.
I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Oklahoma and the
United States of America and that this release shall be governed by and interpreted in accordance with the laws of the State of Oklahoma.
I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the
invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be
enforceable. (Initial ________)
8.
I enter into this agreement freely and voluntarily in consideration of the permission to participate as a FEED volunteer. I understand that
this agreement is contractual and binding upon me. (Initial ________)
I certify the above information is correct and I HAVE READ THE Release and Waiver of Liability in its entirety. I have been given adequate
time to consider whether or not I agree to the terms hereof. In an emergency, I give my permission to a licensed physician to hospitalize,
anesthetize, or perform surgery as needed. I understand that every reasonable effort will be made to contact my family before these actions are
taken.
I have also had every opportunity necessary to ask questions concerning the risks and hazards I am assuming in each of the countries
I will visit or work in. I also have had adequate time to review, analyze and think of this document’s contents, before signing the
document.
Signature:
Date:
State of
County of
Sworn to and subscribed before me this ___ day of
, 20
Signature
My commission expires
3
CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE
WITH THE FCRA (Fair Credit Reporting Act)
Date:
DL#:
DL State
Last Name:
First Name:
Middle Initial:
Current Address:
City*
Date of Birth**
County*
State*
Zip Code*
Social Security Number**
Previous Address #1
Previous Address #2
This authorization and consent for release of personal information acknowledges that FEED THE CHILDREN, INC. (Hereafter
referred to as "Company") and/or its agent, Investigative Concepts, Inc., may now, or at anytime I am assigned to, volunteer
with or employed by this Company, conduct investigations whether the records are of a public, private or confidential nature.
These investigations might include, but are not limited to, searches of educational institutions attended; state driving records;
financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial
statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or
against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in
either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history
information of file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers'
compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or
similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the
National Personnel Records Center, or other custodian of my military service record, to release to Investigative Concepts, Inc.
the following information and/or copies of documents from my military service record: DD214, service record, and any
disciplinary records.
I understand that these searches will be used to determine work assignment or employment eligibility under the Company's
employment or volunteer policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to
the authorized representatives of the Company. In addition, I release and discharge the Company and its agent and
associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge
or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the
Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained
and to receive, upon written request, a disclosure of the background report. I also understand that I may request a copy of
the report from Investigative Concepts, Inc, at P.O. Box 471832 Tulsa, OK or telephone number 918-286-7059. After reading
this document, I fully understand its contents and authorize the background verification.
* AS SHOWN ON THE ORIGINAL APPLICATION
** TO BE USED ONLY FOR CRIMINAL HISTORY SEARCHES, AND NOT A PART OF THE PERSONNEL FILE.
Note: The applicant may request a copy of the consumer report by checking the following box
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND
COMPLETE. I UNDERSTAND THAT IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE THAT THE
GROUNDS FOR THE CANCELING OF ANY AND ALL OFFERS OF EMPLOYMENT WILL EXIST AND MAY BE USED AT
THE DISCRETION OF THE COMPANY.
Signed this ________day of __________________, 20__.
Applicant (print name):
Applicant Signature: