Join Team MN-DAK

Team MN-DAK Application

Today's Date*

Name*

First Last

Date of Birth*

mm/dd/yyyy

Email*

Phone*

Please select if the phone number you entered above is a mobile, home or work number?*

Address*

Street Address Address Line 2 City State ZIP Code

Connection to Donation/Transplantation

Relationship to Donation/Transplantation*

I am a member of a donor family.
I am a recipient.
I am a member of a recipient family.
I am waiting for an organ transplant.
I am a living donor.
Other.

If OTHER, please provide relationship to donation/transplantation below.*

My relationship to donor*

Donor’s name*

Recipient’s name*

My relationship to recipient*

Date of Donation*

Type of transplant*

Example: Heart, kidney, lungs, eyes, tissue.

Date of Transplant*

Transplant Center*

Participation

Click here to review the Team MN-DAK member participation guidelines, and then select your team member type below.

Select your team member type.

Primary Team Member
Support Team Member

Have you ever attended or participated in the Transplant Games?

Yes
No

If yes, please provide number of years you've attended or participated:

Events you are interested in competing in at the Games:

Click here to view event list.

Tell us why you’re interested in joining Team MN-DAK?

Confidentiality and Photo Consent

As a member of Team MN-DAK, we ask that you follow a code of ethics. These ethics should guide your behavior, as one of our most fundamental responsibilities concerns confidentiality. During the course of your involvement with Team MN-DAK, you may, on occasion, have access to confidential information. Your work may bring you information of a personal nature about the people that LifeSource serves, or about the operations of LifeSource or our team members. Our Code of Ethics states that you may not repeat any information of a confidential nature to anyone. Neither may you use any information received to your personal advantage. Confidentiality is a fundamental right of those we serve, and it is guaranteed through your adherence to our Donate Life Ambassador expectations. Please sign the confidentiality statement below as part of your Team MN-DAK application with LifeSource.

Confidentiality Statement*

The Board of Directors calls to your attention the fact that all Team MN-DAK Team Members assume an obligation to conduct themselves in accordance with the accepted principle to hold confidential all information concerning patients, donors, and recipients. On a regular basis, Team MN-DAK Team Members may have access to highly confidential medical information from LifeSource member transplant programs and donor hospitals. On no occasion will a Team MN-DAK Team Member divulge to any unauthorized individual information regarding laboratory, medical, surgical, social, or other related information.

Team MN-DAK Team Members must also refrain from revealing any confidential information concerning employees or business operations. Unauthorized release of any and all confidential information at LifeSource may be cause for termination of a volunteer relationship.

I have read the above statement, I understand the contents, and I agree, unless authorized, to withhold confidential information.

Confidentiality Agreement Signature*

Social Media Photo Consent*

LifeSource may use Team MN-DAK photos on social media sites to help show the positive impact donation and transplantation. Please check “no” if you do NOT want any photos of yourself shared.

I give LifeSource permission to use any photos of myself on social media.
I DO NOT give LifeSource permission to use any photos of myself on social media.

Media Consent*

I give LifeSource permission to use my name/photo in future publications or to give to the media.
I DO NOT give LifeSource permission to use my name/photo in future publications or to give to the media.

Join Team MN-DAK

Team MN-DAK Application

Connection to Donation/Transplantation

Participation

Confidentiality and Photo Consent

Team MN-DAK Participation

Interested in joining Team MN-DAK?

Join Team MN-DAK

Team MN-DAK Application

Connection to Donation/Transplantation

Participation

Confidentiality and Photo Consent

Team MN-DAK Participation

Primary Team Members

Support Team Members

Interested in joining Team MN-DAK?