Scroll to see more shifts & complete your submission at the bottom of the page.Click here to scroll down.
Required fields are marked with an asterisk (*). First Name *
Last Name *
Address *
City *
State *
Zip Code *
Mobile Phone Number *
Birthdate *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
Gender *
T-Shirt Size *
Emergency Contact Name *
Emergency Contact Number *
Have you volunteered for the Marine Corps Historic Half before?
If so, how many times?
For ALL Medical choose your Medical Certification Status *
If you selected Other Medical Certification Status, please expand *
If you selected Physician, please choose a subspecialty below
If you selected Other, please specify your provider or skill type, i.e. optometry, chiropractor etc.
If you selected Physical Therapist, please elaborate, i.e., sports specialist, CSCS, venue coverage experience *
Are you qualified and competent to start IV's *
State of Medical License (if not licensed, please choose N/A) *
Medical License Number (Enter N/A is this isn't applicable to you) *
Medical License Expiration Date (Month/Day/Year) (Enter N/A is this isn't applicable to you) *
If you selected Student, which type are you? (If this isn't applicable, please select N/A) *
As a Volunteer what is your military affiliation? *
If you selected a military affiliation, which branch of service? Write N/A if this doesn't apply *
Which Command (i.e. FBCH, WRNMMC, MCBQ) do you work for? Write N/A if this doesn't apply to you
If you selected Active Duty, Reservist or Govt Civilian, do you possess a valid BASIC MOTOR VEHICLE OPERATORS CERTIFICATE (BMVOC) license to drive a government vehicle? * *
Additional Comments for Volunteer Coordinator or Component Lead i.e., Medical Lead
What is your radio "Call Sign"
Are you between 5'5" and 6'2" and slender in build to fit in the costume? *
Disclaimer
MARINE CORPS MARATHON PUBLICITY RELEASE
I hereby grant permission to the Marine Corps Marathon and its sponsors to use all information submitted in my application, and any photograph, videotape, motion pictures, recording and any other record of this event including race results, my likeness, name and completion time for any lawful purpose related to the race and post-race publicity. The United States Government has requested that I grant, release, and discharge certain rights arising from my appearance, or the appearance of an infant or minor child for whom I execute custody, in any picture, video, advertisement, or other recording or presentation as a result of my participation in the Marine Corps Marathon (MCM), Marine Corps Historic Half, MCM Event Series and other related events. I hereby grant and release to the United States Government the right to use my name, likeness, and personal information, or that of said infant or minor child, in any manner, and to photograph, videotape, make motion pictures, recordings or any other record of; to reproduce, duplicate, publish, exhibit, use or transmit the same or any parts thereof, by any means, in any manner and for any purpose whatsoever; and to do the same perpetually. This voluntary grant and release will not be made the basis of a future claim of any kind against the United States Government. I release and discharge the United States Government from any cause of action arising from my participation or the participation of the infant or minor child in the production. This grant, release, and discharge shall inure to the benefit of the United States Government, and its officers, agents, servants, and employees when acting in their official capacities; and to persons, firms or corporations contracting with the United States Government and state and local government entities supporting these events, and their heirs, executors, administrators, successors, or assigns; and to any other persons lawfully reproducing, distributing, exhibiting, or otherwise using the said production or any portion thereof. OMB NO.: 0703-0053
AGENCY DISCLOSURE STATEMENT
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (OMB#0703-0053). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a current valid OMB control number.
Volunteer Agreement, DD Form 2793, May 2009
Installation: Marine Corps Base Quantico
Program: Marine Corps Marathon
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved volunteer services and liability for tort claims as specified in 10 U.S.C. Section 1588(d)(2). I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be bound by the laws and regulations applicable to voluntary service providers, and agree to participate in any training required by the installation or unit in order for me to perform the voluntary services that I an offering. I agree to follow all rules and procedures of the installation or unit that apply to the voluntary services that I am offering.
In accordance with the authority in DoD Directive (DoDD) 5525.20 and the June 29, 2018 Deputy Secretary of Defense approval of the June 8, 2018 Under Secretary of Defense for Personnel and Readiness and Under Secretary of Defense for Intelligence Memorandum, all volunteers will be subject to a review utilizing publicly available information on the appropriate State, territory, or tribal jurisdictions’ websites or by searching the National Sex Offender Public Website (NSOPW).
VOLUNTEERS - PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 5013; 10 U.S.C. 5041; DoDI 1015.15; DoDI 1100.21; DoD 7000.14-R Vol 13; SECNAVINST 1700.12B; MCO 5380.2; MCM Charter dtd 27 Mar 2017; and SORNs M01710-2 and NM05000-2.
PURPOSE: Information requested is used to acknowledge and document the volunteer agreement for Marine Corps Marathon Organization (MCMO) before the statutory individual is allowed to provide volunteer services.
ROUTINE USES: Information may be disclosed to current authorized contractors and vendors to accomplish a function related to this system of records. Complete lists and explanations of the applicable routine uses are published in the authorizing SORNS available at https://pclt.defense.gov/DIRECTORATES/Privacy-and-Civil-Liberties-Directorate/Privacy/SORNs/.
DISCLOSURE: Voluntary. However, lack of a signed volunteer agreement will limit MCMO support and eliminate certain benefits to individuals donating voluntary services to MCMO.
MARINE CORPS MARATHON PUBLICITY RELEASE
I hereby grant permission to the Marine Corps Marathon and its sponsors to use all information submitted in my application, and any photograph, videotape, motion pictures, recording and any other record of this event including race results, my likeness, name and completion time for any lawful purpose related to the race and post-race publicity. The United States Government has requested that I grant, release, and discharge certain rights arising from my appearance, or the appearance of an infant or minor child for whom I execute custody, in any picture, video, advertisement, or other recording or presentation as a result of my participation in the Marine Corps Marathon (MCM), Marine Corps Historic Half, MCM Event Series and other related events. I hereby grant and release to the United States Government the right to use my name, likeness, and personal information, or that of said infant or minor child, in any manner, and to photograph, videotape, make motion pictures, recordings or any other record of; to reproduce, duplicate, publish, exhibit, use or transmit the same or any parts thereof, by any means, in any manner and for any purpose whatsoever; and to do the same perpetually. This voluntary grant and release will not be made the basis of a future claim of any kind against the United States Government. I release and discharge the United States Government from any cause of action arising from my participation or the participation of the infant or minor child in the production. This grant, release, and discharge shall inure to the benefit of the United States Government, and its officers, agents, servants, and employees when acting in their official capacities; and to persons, firms or corporations contracting with the United States Government and state and local government entities supporting these events, and their heirs, executors, administrators, successors, or assigns; and to any other persons lawfully reproducing, distributing, exhibiting, or otherwise using the said production or any portion thereof. OMB NO.: 0703-0053
AGENCY DISCLOSURE STATEMENT
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (OMB#0703-0053). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a current valid OMB control number.
Volunteer Agreement, DD Form 2793, May 2009
Installation: Marine Corps Base Quantico
Program: Marine Corps Marathon
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved volunteer services and liability for tort claims as specified in 10 U.S.C. Section 1588(d)(2). I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be bound by the laws and regulations applicable to voluntary service providers, and agree to participate in any training required by the installation or unit in order for me to perform the voluntary services that I an offering. I agree to follow all rules and procedures of the installation or unit that apply to the voluntary services that I am offering.
In accordance with the authority in DoD Directive (DoDD) 5525.20 and the June 29, 2018 Deputy Secretary of Defense approval of the June 8, 2018 Under Secretary of Defense for Personnel and Readiness and Under Secretary of Defense for Intelligence Memorandum, all volunteers will be subject to a review utilizing publicly available information on the appropriate State, territory, or tribal jurisdictions’ websites or by searching the National Sex Offender Public Website (NSOPW).
VOLUNTEERS - PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 5013; 10 U.S.C. 5041; DoDI 1015.15; DoDI 1100.21; DoD 7000.14-R Vol 13; SECNAVINST 1700.12B; MCO 5380.2; MCM Charter dtd 27 Mar 2017; and SORNs M01710-2 and NM05000-2.
PURPOSE: Information requested is used to acknowledge and document the volunteer agreement for Marine Corps Marathon Organization (MCMO) before the statutory individual is allowed to provide volunteer services.
ROUTINE USES: Information may be disclosed to current authorized contractors and vendors to accomplish a function related to this system of records. Complete lists and explanations of the applicable routine uses are published in the authorizing SORNS available at https://pclt.defense.gov/DIRECTORATES/Privacy-and-Civil-Liberties-Directorate/Privacy/SORNs/.
DISCLOSURE: Voluntary. However, lack of a signed volunteer agreement will limit MCMO support and eliminate certain benefits to individuals donating voluntary services to MCMO.
Sign here to show you accept the terms stated above for yourself or for a minor Volunteer for which you are the parental guardian.
