MUNTINLUPA JUNIOR RESCUE TEAM
(10 MOST OUTSTANDING YOUTH ORGANIZATION AWARDEE OF 2008)
MEMBERSHIP FORM
(Organization Copy)
LOCATION: _______________
Year of Membership: ______
PERSONAL INFORMATION:
NAME: _____________________________________________________________
(Surname)
(First name)
(Middle name)
2X2
PHOTO
ADDRESS: __________________________________________________________
__________________________________________________________
GENDER: ( ) Male ( ) Female
AGE: _____
CIVIL STATUS: ( ) Single ( ) Married
OCCUPATION: ________________
DATE OF BIRTH: ________________
PLACE OF BIRTH: _____________
CONTACT NUMBER/s:
NATIONALITY: _______________
 TELEPHONE: __________________
RELIGION: _______________
 MOBILE PHONE: ________________
YEAR OF RESIDENCY IN MUNTINLUPA: _________
EMAIL ADDRESS: ____________________________________
NICKNAME: _______________
PARENTS NAME:
FATHER’S NAME: ___________________________________________________
(Surname)
(First name)
(Middle name)
OCCUPATION: _______________
CONTACT NUMBER/s: _______________
ADDRESS: __________________________________________________________
__________________________________________________________
MOTHER’S NAME: ___________________________________________________
(Surname)
(First name)
(Middle name)
OCCUPATION: _______________
CONTACT NUMBER/s: _______________
ADDRESS: __________________________________________________________
__________________________________________________________
EDUCATIONAL BACKGROUND:
ELEMENTARY: ______________________________________________
HIGHSCHOOL: ______________________________________________
COLLEGE: __________________________________________________
AFFILIATION/s:
NAME OF ORGANIZATION/s
______________________
______________________
______________________
POSITION
______________________
______________________
______________________
YEAR
______________________
______________________
______________________
AWARDS & RECOGNITION/s:
AWARD/s:
______________________
______________________
______________________
AWARD GIVING BODY
______________________
______________________
______________________
YEAR
______________________
______________________
______________________
PERSON TO NOTIFY IN CASE OF EMERGENCY:
NAME: ______________________________________________________
ADDRESS: ___________________________________________________
CONTACT NUMBER/s: ________________________________________
MUNTINLUPA JUNIOR RESCUE TEAM
(10 MOST OUTSTANDING YOUTH ORGANIZATION AWARDEE OF 2008)
WHERE HAVE YOU HEARD “MUNTINLUPA JUNIOR RESCUE TEAM”?
___ INTERNET
___ NEWSPAPER
___ STREAMERS OR TARPS
___ FRIENDS
___ OTHER: __________________
(PLEASE SPECIFY)
HAVE YOU HAD ANY OG THE FOLLOWING DISEASES? CHECK EACH BLOCK.
HEART DISEASE OR ATTACK
HIGH BLOOD PRESSURE
RHEUMATIC FEVER
ANEMIA
STROKE
ULCERS
TUBERCULOSIS (TB)
ASTHMA
ALLERGIES OR HIVES
DIABETES
AIDS
HEPATITIS
DRUG ADDICTION
HEMOPHILIA/BLOOD DISEASE
EPILEPSY OR SEIZURES
FAINTING OR DIZZY SPELLS
NERVOUSNESS
PSYCHIATRIC TREATMENT
VENEREAL DISEASE
(SYPHILIS, GONORRHEA, CHLAMYDIA)
OTHERS: ______________________________
(PLEASE SPECIFY)
ARE YOU TAKING ANY MEDICINES NOW? __________
IF YES, INDICATE: ___________________
DO YOU BLEED FOR A LONG TIME WHEN THERE IS A CUT? _________
I DECLARE THAT THE ABOVE INFORMATIONS ARE CORRECT. I UNDERSTAND THAT
FALSIFICATION OF ANY INFORMATION WILL BE CONSIDERED SUFFICIENT TREASON FOR MY
DISMISSAL FROM THE ORGANIZATION, WHENEVER SUCH FALSIFICATION BECOMES KNOWN.
I, HEREBY UNDERSTAND AND ORIENTED PROPERLY TO THE COURSE OF THIS RIGID
TRAINING FOR JUNIOR RESCUE AND ALLOWED BY MY PARENTS / GUARDIAN AND AGREED
TO ALL RULES AND CONDITIONS SET BY MUNTINLUPA EMERGENCY RESPONSE GROUP AND
MUNTINLUPA JUNIOR RESCUE TEAM.
____________________________
____________________________
PARENT/GUARDIAN SIGNATURE
(SIGNATURE OVER PRINTED NAME)
SIGNATURE OVER PRINTED NAME
Contact us at:
mjrt_2006@yahoo.com
20mjrt06@gmail.com
Person to Notify:
Richard Louie Madarang - SMART – 0928-6528428
(PRO)
GLOBE – 0906-5730560