New Member Information Please submit this form to the President when becoming a member, Name:_________________________________________________ Address: _______________________________________________ City__________________ State_______ Zip Code____________ Home Phone:________________ Cell Phone:_________________ Email:_________________________________________________ Birth Date:________________ Circle One: Medical Member

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Administrative Member

If medical member please provide the information below to be used to create an ID badge for you. Personal medical information will be sealed inside to be accessed only in the case of an emergency.

Certification Level: EMT-B

EMT-P

PHRN

Certification #: ___________________ Expiration:_____________ Emergency Contact: Name__________________________________________________ Phone Number 1:_________________________________________ Phone Number 2:_________________________________________

Allergies:_______________________________________________ Medications:____________________________________________ Medical History:_________________________________________ Blood Type:___________ Organ Donor: YES

NO

Family Doctor:__________________________________________

Preferred Hospital:___________________ or

Closest