Date: _____________________

Name: __________________________________________________

Address: ___________________________________________________  

City: ____________________________________   State: _________   Zip:_________ 

Home Phone:  ________________  Mobile Phone: _______________

E-Mail Address: ______________________________________________   

Social Security Number: ___________________   Type of Certification :  __________

Date Certification Expires: ____________   Service Affiliation: ____________________

Please complete the following emergency contact and medical information so that we can provide care for you in the event of a problem.

Emergency Contact: _____________________________________

E.C. Home Phone:  E.C. Cell Phone:_____________________________

Physician: ____________________ Hospital: _________________________

Medical History: _________________________________________________

Allergies: _______________________________________________________

Medications: _____________________________________________________

Insurance Information: _____________________________________________

My interest in RRAMS is Disaster Response only   or  Disaster Resp & Event Standbys 

Shirt Size: ___________   (Shirts are Event shirts which cost $25)

Comments or Special Skills:  ______________________________________________

Name of member recommending you for membership: __________________________

I have read and agree to the policy and procedures of the SPEMS RRAMS Team.  Yes