Join The N.N.C.R.TEAM

Please fill out all of the information below to the best of your ability.

This is to help us better understand your needs, and improve your overall experience.

All information will be sent to a team coordinator and kept 100% confidential.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance by

Please skip if you're enrolled with IHS

Group Policy or Individual Policy Number

Please skip if you do not have a policy number

Insurance Co. Phone Number

Please skip if you're with IHS

C.I.B. Number

Allergies

Medications

Supplements

Last Tetanus Shot

Waiver & Photo Release

“I/we hereby consent to allow any medical treatment necessary to be administered to myself or my minor son/daughter while traveling to and from, or during the Navajo Nation Christian Response Team. I/we assume full medical, financial, and legal responsibilities for any costs involved in treatment, and release all members of the Navajo Nation Christian Response Team, “Cornerstone Ministries,” “Across Nations” and other participating organizations, from liability for any accidental injury or death. By signing I also give permission to N.N.C.R.T. to use any media content (photo/video/audio recording) of me to be used by the Navajo Nation Christian Response Team to use in their publications and/or Web site and/or videos. I understand that my name may, in some cases, be used with my picture. I agree that I will not be compensated for such usage.

T-shirt Size

Volunteer has watched NNCRT safety video at the bottom of page

All NNCRT volunteers are required to watch safety video before being deployed.

Yes, I have

Across Nations (505) 371-5749

Tim Tsoodle (NNCRT Dir.)

Phone: (505) 264-5159

Email: nmtf1log@msn.com