Membership Application

Personal Information

Title

First Name *

Last Name *

Email Address *

Address *

City *

State *

Zip *

Country

Home Phone Number *

Cell Phone Number *

Date of Birth *

Gender *
Male Female

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?
(A conviction record will not necessarily bar team membership. Factors such as age of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.)

Emergency Contact Information

Contact Name *

Relation to Contact *

Contact Phone Number *

Contact Alternate Phone Number

Your Connection to Donation

What is your connection to donation and/or transplantation?

Team Membership Type and Responsibilities

Team Iowa Competitor in 2021 Transplant Games

Members must be one of the following: Transplant Recipient (at least 9 months post-transplant by June 2021), Tissue or Cornea Recipient or Living Donor.
Raise $750. Participate in Iowa Donor Network’s Volunteer Program. Attend all Team Meetings.

Team Iowa Supporter

Includes family members and friends of Team Iowa athletes, OPO and eye bank staff.
Supporters will receive a free Team Iowa t-shirt. Additional items (other apparel, pins, etc.) can be purchased separately.

Team Iowa Membership Agreement

I understand and agree to the following terms:

I certify that the information provided in this application is true and correct in all respects without any willful omissions.
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.
I will adhere to Team Iowa's Code of Conduct and Ethics which will be provided to me in detail upon joining the team.
I understand that I am required to provide proof of medical clearance from my physician two months prior to the Transplant Games in August 2021 in order to participate in any events.
I agree to fulfill the fundraising requirements as a member of Team Iowa.

I have read the above statement and understand and agree to its contents.

Membership Application

Personal Information

Education / Employment

Personal Background Information

Emergency Contact Information

Your Connection to Donation

Team Membership Type and Responsibilities

Previous Games Experience

Team Iowa Membership Agreement

Our Vision:

Understanding Donation

Donor Families

Professional Partners

Transplant Recipients

Membership Application

Personal Information

Education / Employment

Personal Background Information

Emergency Contact Information

Your Connection to Donation

Team Membership Type and Responsibilities

Previous Games Experience

Team Iowa Membership Agreement

Our Vision: