Membership Application: Together Everyone Achieves More

krobinson.teamforall@gmail.com | www.teamforall.org

APPLICATION FOR MEMBERSHIP

Location & Application Type Location Is this Membership Application for Youth or Adult?

DEMOGRAPHICS:

Name First Last
Address Address City State Zip Code
Contact Email Phone
Race and Ethnicity Classifications Sex Race Ethnicity
Age & Family Size Age Family Size
Date of Birth / MM / DD YYYY
SSN & MA# SSN MA#
School & Current Grade School Grade
Parent/Guardian Name Phone
Status Smoker Employed Marital Status
Preference Religious Language
Social Media Facebook Instagram

MEDICAL INFORMATION:

Primary Doctor Name Phone Fax Address City State Zip Code
Allergies
Emergency Contact Name Phone Address City State Zip Code
RELEASE OF INFORMATIOM CONSENT/ AUTHORIZATION TO USE PHOTOGRAPHS and/or AUDIO-VISUAL:

By clicking the submit button below, I hereby agree to and accept the following terms and conditions:

By signing below, you hereby authorize TEAM, Inc. to contact the identified Emergency Contact in the event of a medical/mental health concern or emergency, an attempt to contact/locate to participate in sustaining services provided by TEAM, Inc. The release of information will be in effect for one (1) year after the date of your signature. A photocopy or facsimile may be accepted in lieu of the original signed form and this consent is revokable except to the extent that action has been taken on it already.

By signing below, you hereby authorize TEAM Inc., or one of their professional vendors (photographer/videographer) or project sponsor to use, reproduce and/or publish photograph, and/or video that may pertain to me including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSA’s), or for other related endeavors. This Material may also appear on the Corporations or project sponsors internet webpage. This authorization is continuous and may only be withdrawn by a specific recession of this authorization. Consequently, the Corporation or project sponsor may publish materials, use your name, photograph, and/or make reference to me in any manner that the Corporation or project sponsor deems appropriate in order to promote/publicize service opportunities.

By signing below, I certify that I hold harmless TEAM, Inc. and any volunteers from any injury, illness or conditions that may arise as a result of my membership (This registration form will serve as an official membership for TEAM, Inc.)

We are excited to have you consider our organization to assist you with your mental and physical wellness. Upon registration, it could take up to approximately 6 weeks for the enrollment process to be completed. We cannot service you until we receive authorization from the Maryland Department of Mental Health and Hygiene. We will notify you upon receipt of the authorization.