Michiana Traffic Control
P.O. Box 2144
Elkhart, IN. 46515
michianatrafficcontrol@yahoo.com
Date filled out:____/____/____
Name:_________________________________________________
Address:_______________________________________________
_______________________________________________
City:___________________________ State:_________________
Zip:________
Phone number:__________________________ E-Mail:______________________
Cell Phone Number:____________________________
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How
did you find out about MTC?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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Volunteerism
Question:
NOTE: We are an unpaid volunteer unit.
1. What times of the day can you volunteer? Please place a check mark in the appropriate lines.
_____
(6-10 AM) ________(10-3 PM) _______ (3-9 PM) _______ (9-12PM)
_____ (10 PM-6 AM).
2.
Are there specific days that you are unable to assist us?
_____________________________________________________________
_____________________________________________________________
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Medical
and Emergency Information:
I agree that if I am approved for membership, that I will disclose the names of any and all
medicines/medical conditions that I am to take as well as the name of my physician(s). Please check yes or no.
______
(YES) _____ (NO).
Name of Emergency Contact:________________________________________
Address:_________________________________________________________
City:_____________________
State:_______________ Zip:_____________
Phone Number:________________________ Alt. #_______________________
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References:
Note:
These will be contacted either before/after a personal interview.
My Work/School that I attend:_______________________________________
Address:________________________________________________________
City:________________________
State:_______________ Zip:___________
Person to contact:_________________________________________________
How
long have you been working/attending school?_________ months/years.
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Personal
References:
Do not put down any MTC members!
Reference #1:_____________________________________________________
Address:_________________________________________________________
City:_____________________
State:_________________ Zip:_____________
Phone number:________________________
How long have you known this individual?__________ months/years
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Reference #2:______________________________________________________
Address:__________________________________________________________
City:_____________________
State:__________________ Zip:_____________
Phone number:_______________________________
How long have you known this individual?_______________ months/years
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Reference #3:
Name:_________________________________________
Address:__________________________________________________________
City:____________________
State:________________ Zip:________________
Phone number:_______________________
How long have you known this individual?_________ months/years?
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Junior
Membership Parental Waiver:
(This section is for teenagers 15-17 years of age.)
In order to qualify/continue
membership, you will need to maintain a B- average in all grades to qualify for membership/continued membership. (Consult
By-Laws for further details). You will also need a parental signature below
I ___________________________
agree to allow my son/daughter to participate in the Michiana Traffic Control group.
Date:_____/______/______
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Procedures for approving/denying applications-membership:
1. After your application is printed, filled out, accompanied by a police background check, and mailed to
the address noted at the top of the page, it will be examined and..
2. References will be contacted.
3. You will be asked to come into an interview with our team at the next scheduled meeting that we have (either
Executive/General) team meeting.
4. The Executive Staff will make a final review of the application and will take a vote to either accept / deny
you for membership.
5. You will be contacted confirming or denying your membership within 3 weeks.
