PLEASE PRINT OUT AND SEND APPLICATION TO THE PO BOX LISTED BELOW
Animals’ Disaster Team, P.O. Box 609205, Cleveland, OH 44109
APPLICATION FOR MEMBERSHIP
DATE __________________________________
FULL NAME _________________________________________________________________
ADDRESS ___________________________________________________________________
COUNTY ____________________________________________________________________
PHONE (DAYS) _____________________________ (EVE) ___________________________
CELL PHONE ______________________________ E-MAIL __________________________
ANIMAL RELATED INTERESTS ________________________________________________
_____________________________________________________________________________
I understand that this application for membership in training with the Animals’ Disaster Team (ADT) must be approved beforeI am considered a member-in-training. I further understand that I am making a personal commitment to participate as a volunteer. I also understand that for this program, I must be 18 years of age or older for Cuyahoga, Lorain or Summit Counties and I must be 16 years of age (with parental consent) or 18 years (no consent needed) to participate in Medina County. I understand there is a Registration Fee of $10.00, which is enclosed.
I understand that I am required to complete the ADT Basic Training program before I can be certified as a member of the ADT. I further understand that I am required to complete all Continuing Education Classes offered to me, as soon as possible after my certification. I also understand that I may be required to complete and pass a recertification test every three years after my initial certification.
I fully understand and accept that there could be a certain degree of physical activity and risk involved with joining this or any disaster management program. For the safety of myself, other team members and the animals, I agree to abide by all rules and regulations established by the Animals’ Disaster Team before, during and after my training process.
______________________________ ________________________________
Signature of Applicant & Date Witness Signature & Date
______________________________________
Signature of ADT Staff Member & Date approved
Registration fee enclosed _________
ADT/Form 100-Membership Application-Rev. 2/09
