2019 Membership Application The Dragonheart Vermont membership runs from Jan 1 - Dec 31.Dragonheart Vermont strives to strengthen and empower breast cancer survivors & supporters through the challenging sport of dragon boating instilling in its members the values of teamwork, fitness & community giving. Questions? Please email email@example.com Step 1 of 6 16% Legal Name* First Middle Last NicknameAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Cell Phone*Home PhoneOccupationEmployerWork PhoneBiological Sex*(For team placement)FemaleMaleDate of Birth*(For team placement) Date Format: MM slash DD slash YYYY Share my contact information on DHVT website (phone number and email address)*YesNoBreast Cancer Survivor (BCS)*YesNoYear of DiagnosisMy breast cancer is metastaticYesNoWhich of the following is true for you? Check all that apply. I can swim I am CPR certified Please notify us of any special circumstance you feel the coach should know to make a reasonable accommodation for you to participate.Type of Membership*VT Paddler ($200)VT New Member ($100)VT Non-Paddler ($100)Associate Member (Out-of-State)($100)VT Student ($75)BCS Metastatic (Free)Volunteer (Free)Lifetime Member (Free)Coach (Free) Please select the division and crew that you would like to paddle with.Breast Cancer Survivor CrewN/ACompetitiveRecreationalORSupporter CrewN/ACompetitive Women <40Competitive Women 40 -49Competitive Women 50 - 59Competitive Women >=60Competitive Men <50Competitive Men 50 - 59Competitive Men >=60Recreational/DevelopmentOptional/Secondary TeamCompetitive Co-Ed <50Competitive Co-Ed 50 - 59Competitive Co-Ed >=60I'm not sure what team to select and would like to discuss with a coachNo thanksYes, pleaseDo you prefer to paddleRightLeftEitherNot sure Dragonheart Vermont is a non-profit organization. Volunteerism keeps our organization running smoothly and aids us in accomplishing our goals. Please select your professional background and areas of expertise and interest.* Agricultural Armed Forces Clerical Craft/Trade Managerial Manufacturing Professional Service & Sales Teaching/Training Technical Other Please describe your other expertise/backgroundIndustry Experience* Accounting Education Film/Music/Entertainment Financial Services/Banking Healthcare Hospitality Information Technology Legal Retail Sailing/Nautical Other Please describe your other industry experience Release of Liability Click here to view the Dragonheart Vermont release of liability.I have read and understood, and agree to the Dragonheart Vermont release of liability*AgreeDo Not AgreeOn the last question you said you do not agree to the release of liability. Unfortunately, you cannot become a Dragonheart Member without agreeing to this release.If this was an error, please change your answer to the prior question. If you would like to ask questions or discuss your concerns, please contact: membershipDHVT@gmail.comUpload Your Photo HereWe’ll need a photo ID for IDBF (International Dragon Boat Federation) and ERDBA (Eastern Regional Dragon Boat Association) races. Give us your best selfie from the shoulders up! EMERGENCY MEDICAL INFORMATIONDoctor's Name*Doctor's Phone Number*Is your tetanus current?*YesNoHave you had a wellness exam in the past year?*YesNoIN CASE OF EMERGENCYEmergency Contact*Relationship to Member*Contact's Home/Cell Phone*Contact's Alternate PhoneINSURANCE INFORMATIONInsurance Company*Subscriber's Name*Relationship to Subscriber*Group Number*Policy Number*MEDICAL INFORMATIONList of Current MedicationsAllergiesPlease list any other medical information that you feel is pertinent to medical personnel in time of an emergency. Membership Benefits:Community involvement and awarenessEligibility to participate in IDBF racesImproved endurance and fitnessOST program (off season training)Regularly scheduled water practices and workshops (in season)Team and individual dragon boat coachingTeam buildingUse of boats, paddles and butt pads (in season)The Dragonheart Vermont Member’s Promise: As a DHVT member, I promise to:Follow the mission of strengthening and empowering breast cancer survivors & supporters throughout the challenging sport of dragon boating.Instill the organization’s core values of teamwork, fitness and community giving.Attend membership meetings and practices regularly.Volunteer at DHVT fundraising and community events.Help the organization maintain the positive energy throughout the membership and community. PaymentSuccessful registration requires minimum $50 payment with submission of form.Dues are paid via credit card, in full, by May 15, 2019. Optional, equal installment payments via credit card are due on:2/1/19 (or when submitting your application)3/1/194/1/195/1/19Note: Membership dues must be paid in full prior to participating in practices or races.After submitting this form you will be taken to the Payment Page.NameThis field is for validation purposes and should be left unchanged.