Name:_________________________________________________
Address:_______________________________________________
_______________________________________________
City:___________________________ State:_________________ Zip:________
Phone number:__________________________ E-Mail:______________________
Cell Phone Number:____________________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++
How did you find out about MTC?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Volunteerism Question:
NOTE: We are an unpaid volunteer unit.
1. What times of the day can you volunteer? Please place a check mark in the appropriate lines.
_____ (6-10 AM) ________(10-3 PM) _______ (3-9 PM) _______ (9-12)
_____ (10 PM-6 AM).
2. Are there specific days that you are unable to assist us?
_____________________________________________________________
_____________________________________________________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Medical and Emergency Information:
I agree that if I am approved for membership, that I will disclose the names of any
and all medicines/medical conditions that I am to take as well as the name of my physician(s). Please check yes
or no.
______ (YES) _____ (NO).
Name of Emergency Contact:________________________________________
Address:_________________________________________________________
City:_____________________ State:_______________ Zip:_____________
Phone Number:________________________ Alt. #_______________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
References:
Note: These will be contacted either before/after a personal interview.
My Work/School that I attend:_______________________________________
Address:________________________________________________________
City:________________________ State:_______________ Zip:___________
Person to contact:_________________________________________________
How long have you been working/attending school?_________ months/years.
++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Personal References:
Do not put down any MTC members!
Reference #1:_____________________________________________________
Address:_________________________________________________________
City:_____________________ State:_________________ Zip:_____________
Phone number:________________________
How long have you known this individual?__________ months/years
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - -
Reference #2:______________________________________________________
Address:__________________________________________________________
City:_____________________ State:__________________ Zip:_____________
Phone number:_______________________________
How long have you known this individual?_______________ months/years
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - -
Reference #3:
Name:_________________________________________
Address:__________________________________________________________
City:____________________ State:________________ Zip:________________
Phone number:_______________________
How long have you known this individual?_________ months/years?
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Junior Membership Parental Waiver:
(This section is for teenagers 15 1/2-17 years of age.)
In order to qualify/continue membership, you will need to maintain a B- average in all grades to qualify for
membership/continued membership. (Consult By-Laws for further details). You will also need a parental signature
below
I ___________________________ agree to allow my son/daughter to participate in the Michiana Traffic Control
group.
Date:_____/______/______
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