Team Iowa Membership Application

Personal Information

Member Title -- Please select --DRMISSMRMRSMS

First Name

Last Name

Email Address

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

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Home Phone Number

Cell Phone Number

Date of Birth

Gender

Preferred Pronouns

If not listed above, please list your preferred pronouns below

Education / Employment

Occupation

Employer or School/University

City

State

Zipcode/Postcode

Personal Background Information

Have you ever been convicted of a crime or violation, other than a minor traffic violation? Are there criminal charges now pending against you other than a minor traffic violation? -- Please select --YesNo

Please explain:

Emergency Contact Information

Contact Name

Relation to Contact -- Please select --SpouseParentSiblingSon/DaughterFriendCo-WorkerNeighbor

Contact Phone Number

Contact Alternate Phone Number

Your Connection to Donation

What is your connection to donation and/or transplantation? -- Please select --Transplant RecipientFamily Member of Transplant RecipientFamily Member of an Organ, Tissue or Eye DonorLiving DonorFamily Member of Living DonorTeam Iowa Supporter

Organ(s) or Tissue(s) Received

Date of Most Recent Transplant

Transplant Hospital

Name of Loved One

Organ(s) Donated

Relationship to Recipient

Relationship to Donor

Where (State or Hospital) Donation Occurred

Donation Date

Please Explain

Team Membership Type and Responsibilities

Previous Games Experience

Have you ever attended or participated in the Transplant Games? -- Please select --YesNo

Events you plan to compete in:

Additional Information

Team Iowa Membership Agreement

I understand and agree to the following terms:

1. I certify that the information provided in this application is true and correct in all respects without any willful omissions.
2. I understand that I will be screened at Iowa Donor Network's cost for a background check. The background investigation shall include, but is not limited to: Motor Vehicle Records Check, Social Security Trace, Child Abuse Registry Check, Criminal History Check, Education Verification and/or employment verifications. A positive finding for any of the above, such as a conviction or court-imposed penalty for a crime, may preclude me from consideration as a member of Team Iowa.
3. I will adhere to Team Iowa's Code of Conduct and Ethics which will be provided to me in detail upon joining the team.
4. I understand that I am required to provide proof of medical clearance from my physician two months prior to the Transplant Games in August 2022 in order to participate in any events.
5. I agree to fulfill the fundraising requirements as a member of Team Iowa.