TTA Member Application
Please complete application and return before 12/31/17. Fill out one application per Team Member (some families may have more than one team member).
Member First Name *
Your answer
Member Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone number *
Your answer
Is Member over 18? *
If Member is under 18, who is the Guardian?
Your answer
Have you been a Member before this year? *
Are you a... *
What is your transplanted organ or tissue?
Your answer
When was your transplant?
Your answer
What is your t-shirt size? *
Required
Travel Allowance
Transplant Team AZ offers a travel and lodging allowance to its members based on funds available. This application and team member fee must be received no later than December 31, 2017 to be considered for travel allowance (the sooner the better!).
Do you want to apply for a Travel Allowance? *
I understand the following statements regarding the Travel Allowance Assistance I will receive:
1. I will register on my own with Transplant Games of America and pay my own registration fees
2. To receive the travel allowance, the I will participate in 18 hours of volunteer work for the Transplant Team AZ
3. If I am unable to complete the volunteer hours before June 30, 2018, I may not be eligible for financial assistance
4. I will attend the 2 of the team meetings if I am able
5. The travel allowance will be paid to competitor (or guardian) if funds are available
6. I will stay at the hotel of the TTA’s choice
7. The Travel Allowance is limited to travel and lodging, no other expenses will be considered
Consent
Are you interested in organizing or leading a fundraising campaign? *
What are your skills or areas of interest for fundraising events?
Your answer
Signature
I will be attending Transplant Team AZ’s events and meetings at my own free will and by signing this application, I will assume all the risks of participation in any/all associated activities. I will sign the attached Waiver and Release Form and pay the $25 membership fee before May 15, 2018. By typing my name below, I agree to the above statements.
Full Name of person signing application
Your answer
How to pay your membership fee
1. Mail. Please print out the Waiver found here http://www.transplantteamaz.org/tga/forms, sign and send with a check for $25 to Transplant Team Arizona, PO Box 36122, Phoenix, AZ, 85067
2. Paypal. Go to http://www.transplantteamaz.org/donate and scroll to the bottom. Enter Member name and click "Pay Now"
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