2018 Cabin and Lookout Host Registration

Thank you for your interest in hosting a cabin or lookout with the Selway Bitterroot Frank Church Foundation!

**All New & Interested Applicants PLEASE NOTE: At this time, our schedule for the 2018 cabin hosting is full. We are currently accepting applications for a waiting list for each of the stations. Please e-mail Courtney Wall courtneywall@selwaybitterroot.org to be added to the waiting list or for more information.

1. Please provide us with the following contact information:

First Name *This question is required.

Last Name *This question is required.

Title

Company/Organization

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Postal Code *This question is required.

Country *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required. This question requires a valid number format.

Fax Number This question requires a valid number format.

Mobile Number This question requires a valid number format.

2. Selway Bitterroot Frank Church Foundation volunteers must be at least 18 years of age or older, or accompanied by a parent or guardian. Please select one of the following which best describes you:

3. If under 18 years of age, please list the name of parent(s) or guardian(s) who will be accompanying you.

4. Please select the hosting opportunities you are interested in.

Moose Creek Ranger Station
Shearer Guard Station
Fish Lake Guard Station
Saint Mary's Peak Lookout

5. What date are you available to begin cabin or lookout hosting? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

6. What date will your cabin or lookout hosting commence? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

7. Do you have friends, family, or others that will be joining you at the cabin or lookout? (Please note, they must complete their own registration form.)

8. Have you volunteered with the Selway Bitterroot Frank Church Foundation in some capacity before?

9. If you have volunteered with us before, please tell us when.

10. Do you carry health insurance?

11. Insurance Provider Information

Insurance Company
Policy Number
Insurance Company Phone Number
Doctor's Name
Doctor's Phone Number
Location of Doctor's Office

12. Are you currently using any medication that EMS should know about in the case of an emergency? If so, please list the medication(s), reason for use, and any potential negative interactions with other medications or substances. *This question is required.

13. Emergency Contact Information

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone Number:
Alternate Phone Number:
Relationship:

All participants must complete this form including the e-signature. For Participants under 18 years of age, one parent or legal guardian must also sign. Selway-Bitterroot Frank Church volunteers may be covered for tort claims and injury compensation by the U.S. Forest Service under the Selway-Bitterroot Frank Church Foundation's sponsored volunteer agreement with the U.S. Forest Service. Tort and injury coverage are conditional upon volunteers working within prescribed safety limits and protocols. At the beginning of each project a Job Hazard Analysis document, which reviews safety concerns and protocols for the project, will be reviewed with all participants. Each participant must sign the Job Hazard Analysis document after the pre-project review. Refusal to signs the document will result in dismissal from the project. The Selway-Bitterroot Frank Church Foundation reserves the right to remove any participant from a project for any reason. By affixing your e-signature to this form, you acknowledge that you have carefully read and understand this form. By affixing your e-signature to this form you also authorize the Selway-Bitterroot Frank Church Foundation to use your/or your child's photo for sale or reproduction in any manner that the Selway-Bitterroot Frank Church Foundation desires, for advertising, display or other uses.

14. ACKNOWLEDGEMENT: I have filled out this information thoroughly and to the best of my knowledge. In respect to those who have donated financially to fund the Selway-Bitterroot Frank Church Foundation's expenses towards these volunteer projects, I will do my best to commit to registering for this project, and will notify SBFC immediately if I must cancel my registration. *This question is required.

E-Signiture
Date
Parent/Guardian E-Signiture
Date

15. Please electronically your registration form here. *This question is required.

Clear

Signature of

2018 Cabin and Lookout Host Registration

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