Nevada MAP Team Member Application

Section 1: Applicant Profile

Name(Required)

First Last

Nickname

Agency & Title(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Application Type(Required)

New Applicant

Update Applicant

Affiliation(Required)

Volunteer

Agency Staff

Partner

Section 2: Language & Demographics

Is English your primary language?(Required)

Yes

If no, please list primary language:

Are you fluent in any language other than English?(Required)

Yes

If yes, please list languages:

Birthdate(Required)

Age(Required)

Gender(Required)

Male

Female

Ethnicity/Race(Required)

White

Hispanic/Latino

Black/African American

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Section 3: Conflict of Interest

Licensed insurance agents and people affiliated with an insurance company, a claims filing service, a financial planning service, Medicare providers, or those who receive reimbursement from Medicare are not eligible for Nevada MAP due to possible conflicts of interest. Are you or a family member affiliated with any of the above?(Required)

Yes

If yes, please explain

Do you intend to use this training for financial gain?(Required)

Yes

If yes, please explain

Section 4: Terms of Participation

By signing this Application, I attest to the following:(Required)

I was provided with an overview of MAP job descriptions, opportunities, and training requirements

I was provided, have read, and understand conflict of interest, confidentiality (HIPPA), and mandated reporter expectations

I agree to abide by all terms, conditions, agreements, and guidelines of MAP

I agree to complete initial, annual, and ongoing MAP training and assessments as required

I agree to make a concerted effort to attend volunteer and/or partner meetings as scheduled

Type Full Legal Name for Signature(Required)

First Last

Date(Required)

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Section 1: Applicant Profile

Section 2: Language & Demographics

Section 3: Conflict of Interest

Section 4: Terms of Participation

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