Team Iowa Membership Application

* required field

Personal Information

Member Title -- Please select --DRMISSMRMRSMS

First Name

Last Name

Name Pronunciation

Email Address

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

County ADAIRADAMSALLAMAKEEAPPANOOSEAUDUBONBENTONBLACK HAWKBOONEBREMERBUCHANANBUENA VISTABUTLERCALHOUNCARROLLCASSCEDARCERRO GORDOCHEROKEECHICKASAWCLARKECLAYCLAYTONCLINTONCRAWFORDDALLASDAVISDECATURDELAWAREDES MOINESDICKINSONDUBUQUEEMMETFAYETTEFLOYDFRANKLINFREMONTGREENEGRUNDYGUTHRIEHAMILTONHANCOCKHARDINHARRISONHENRYHOWARDHUMBOLDTIDAIOWAJACKSONJASPERJEFFERSONJOHNSONJONESKEOKUKKOSSUTHLEELINNLOUISALUCASLYONMADISONMAHASKAMARIONMARSHALLMILLSMITCHELLMONONAMONROEMONTGOMERYMUSCATINEO’BRIENOSCEOLAPAGEPALO ALTOPLYMOUTHPOCAHONTASPOLKPOTTAWATTAMIEPOWESHIEKRINGGOLDSACSCOTTSHELBYSIOUXSTORYTAMATAYLORUNIONVAN BURENWAPELLOWARRENWASHINGTONWAYNEWEBSTERWINNEBAGOWINNESHIEKWOODBURYWORTHWRIGHT

Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and Saba Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the CongoReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Home Phone Number

Cell Phone Number

Preferred Method of Communication Checkboxes

Date of Birth

Gender

Preferred Pronouns

If not listed above, please list your preferred pronouns below

Have you ever served in the military? YesNo

If yes was selected for the previous question, please select the branch you served in. NAAir ForceArmyCoast GuardMarine CorpsNavySpace Force

Dietary Restrictions (Select all that apply)

Unisex Shirt Size Adult XSAdult SmallAdult MediumAdult LargeAdult XLAdult 2XAdult 3XAdult 4XYouth XSYouth SmallYouth MediumYouth Large

Team Iowa Profile Photo for Directory

Please write a short statement about your donation story for your Team Iowa profile.

Team Directory Authorization

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? -- Please select --YesNo

Please explain:

Emergency Contact Information

Contact Name

Relation to Contact -- Please select --Spouse or PartnerParent or GuardianSiblingChildFriendCo-WorkerOther

Contact Phone Number

Contact Alternate Phone Number

Your Connection to Donation

What is your connection to donation? (Select all that apply)

Please fill in the below information based off your connection to donation. If question is not applicable to you put N/A.

Organ(s) or Tissue Received

Date of Most Recent Transplant or Living Donation

Transplant Hospital

Name of Loved One

Organ(s) Donated

Relationship to Recipient

Relationship to Donor or Living Donor

Donation Date

Hospital of Donation

Please Explain

Team Membership Type and Responsibilities

Competitor

Solid Organ Recipients, Living Donors, Bone Marrow Recipients, Cornea Recipients and Tissue Recipients ONLY. At least 9 months post-transplant by June 2024. Competitors must raise $750 and attend all Team Meetings.

Non-Competitor

Donor Families, Supporters, Fans, Sponsors and anyone who is not competing. Non-competitors will receive a free Team Iowa t-shirt. Additional items will be available to purchase. 

Previous Games Experience

Have you ever attended or participated in the Transplant Games? -- Please select --YesNo

Events you plan to compete in:

Additional Information

Team Iowa Membership Agreement

I understand and agree to the following terms:

1. I certify that the information provided in this application is true and correct in all respects without any willful omissions.
2. 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. If I have already completed a background check for Team Iowa, I am required to notify the Team Manager if I should be convicted of a crime or violation after the date of my original background check.
3. I will adhere to Team Iowa's Code of Conduct and Ethics which will be provided to me in detail upon joining the team.
4. I understand that I am required to provide proof of medical clearance from my physician two months prior to the Transplant Games in June 2024 in order to participate in any events.
5. I agree to fulfill the fundraising requirements as a member of Team Iowa.