Start A Chapter - Twilight Wish Foundation

Comments

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Personal Information

Name*

First Last

Birth Date*

Address*

Street Address County City State ZIP Code

Select All That Apply*

Phone Number

Cell Number

Fax Number

Chapter type*

Phone Number*

Cell Number*

Fax Number*

Email*

References

(Please Provide Personal and Professional References)

1. Name*

First Last

Title*

Address*

Street Address County City State ZIP Code

Select All That Apply*

Phone Number

Cell Number

Fax Number

Phone Number*

Cell Number*

Fax Number*

2. Name*

First Last

Title*

Address*

Street Address County City State ZIP Code

Select All That Apply*

Phone Number

Cell Number

Fax Number

Phone Number*

Cell Number*

Fax Number*

Work History

(Including Volunteer Positions)

1. Company Name*

Title*

Address*

Street Address County City State ZIP Code

2. Company Name*

Phone*

Years Employed*

Title*

Address*

Street Address County City State ZIP Code

3. Company Name

Phone*

Years Employed*

Title

Address

Street Address County City State ZIP Code

Phone

Years Employed

Personal Interest

Describe your personal interest in helping the elderly*

Attach any articles or information you feel is pertinent

Drop files here or

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What Area Would You Request Your Chapter Covers?

Population*

Geographic Area*

Approx.# of Nursing Homes*

Approx.# of Assisted Living Facilities*

Disclosure

Have you ever been convicted of or pled guilty to any crime(s)?*

Yes

No

If yes, describe each in full. Also indicate date(s) of crime(s) and in which county and state each took place.*

G. Certification, Consent, and Waiver

I declare that all of the information given by me in this application is true and complete to the best of my knowledge. I consent to the investigation and verification by TWF of all information given in this application to the extent deemed necessary by TWF, including searches of law enforcement and public records (including criminal background checks), contact with former employers and reference interviews. If accepted as a TWF chapter leader, I agree to abide by all TWF rules, regulations, policies and philosophies, and all decisions and directions of any officer or employee of TWF. I acknowledge that my participation in TWF activities may involve travel and/or, in certain circumstances, risk of physical injury. For myself, and on behalf of my heirs and assigns: (1) I willingly and voluntarily accept and assume all such risks of participation and (2) I release and discharge TWF and all persons and entities associated or affiliated with TWF from any and all claims, demands, costs, expenses, and compensation arising out of or in any way relating to my participation at TWF or while present at any TWF sponsored event.

I HAVE READ AND FULLY UNDERSTAND THE FOREGOING, INCLUDING THAT I HAVE GIVEN UP CERTAIN RIGHTS BY MY SIGNING THIS FORM AND AGREEING TO THESE TERMS, AND I SIGN THIS FORM AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT OF ANY KIND. FURTHERMORE, I AGREE TO INFORM TWF IN A TIMELY MANNER IF ANY INFORMATION IN THIS FORM CHANGES.*

Yes

Signature*

Start A New Twilight Wish Foundation Chapter

Personal Information

References

Work History

Personal Interest

What Area Would You Request Your Chapter Covers?

Disclosure

G. Certification, Consent, and Waiver