*First Name

*Last Name

*Email

*Phone

*Today's Date is:

*In what state are you located?

*In what city are you located?

*What is the name of your church or organization? Must be a United Methodist-affiliated organization.

*My position with this organization is: Please indicate your relationship such as Director, Maintenance Supervisor, Church Trustee, etc.

Another person(s) at our facility should also be communicated with about this NOMADS project. If applicable, please include name, position, email address and phone number for additional persons at your facility.

*Our status with NOMADS

We have hosted NOMADS recently and our RV site details have not changed.

We have hosted NOMADS recently but our RV sites/plans have changed.

We have hosted NOMADS in the past, but it has been more than 3 years since we have done so.

We have never hosted NOMADS but have filled out the New Agency Info on the NOMADS website.

This is our first contact with the NOMADS organization. We will expect a call from NOMADS soon.

*Please give a brief description of the work you have planned for the NOMADS team(s). Please specify the work plans for each project, if you are requesting more than one project.

*How many 3-week projects would you like to have during 2013?

Generally we can offer only one or two projects per agency. If you typically host more or would like to, please consider that we have new agencies each season who'd like to be added to our schedule. We certainly will try to accommodate everyone as best we can.

We are requesting 1 project

We'd like to have 2 projects

We'd like to have 3 or more projects and will call the NOMADS office to discuss

*Periods or months in which we COULD host NOMADS

Please mark those that would work for you

*The month we would MOST like to have NOMADS is:

*Maximum # of RVs you'd like on your team(s)

*The RVs will be parking at:

We have RV sites with hookups at our facility where the work will be done.

We don't have RV sites with hookups, so will reserve RV sites at a commercial campground nearby.

RV sites are nearby, at another church or agency, and we have their approval to use those sites.

We don't have RV sites onsite or nearby and need to work something out (please call the NOMADS office).

*Name and physical address of RV parking location

*Will background checks be required? You will be asked to be very specific about what your requirements are on this.

Yes

No

*Will pets be allowed at the RV area or campground (inside RV or on leash outside RV)? Pets are not allowed at "work" or at the job site, but some of our members do travel with pets.

Yes

No

*Hosting Agency Waiver of Liability

Agreement and General Release: (1) In applying for a team(s) of the United Methodist NOMADS, I/we agree that we fully understand the nature and difficulty of the work that we will be asking NOMADS to perform, (2) I/we agree that where permits, licenses and inspections are needed, our organization takes full responsibility, (3) General Release: In consideration of the work to be performed by NOMADS and described in any project application, we hereby indemnify and hold NOMADS, its members, officers, directors and agents harmless from any and all liability and costs (including attorney's fees) related to or arising out of the work performed by NOMADS. This indemnification and hold harmless agreement will survive the completion of any specific project by NOMADS.

Yes, I am an authorized person for this agency and agree to these terms.

No, I/we do not agree. If so, please call NOMADS office.

Other notes or comments about project or RV parking plans

Agency - Request a project for 2013