APPLICATION FOR MEMBERSHIP

 

Name: ______________________________________DOB:_________Age:________

Physical Address: _______________________Phone: _________________________

Mailing Address: _______________________________________________________

Email Address: ________________________________________________________

Employer: ____________________________________________________________

Occupation: ___________________________________________________________

Emergency Contact Number: ______________________________________________

Medical History (check if condition exists):

Severe Headaches_____Hay Fever______Asthma______Heart Trouble_______

Dizziness or Fainting Spells______Eye Trouble (except glasses)______

High or low blood Pressure______Stomach Trouble______Epilepsy_______

Kidney Stones ______ Sugar or Albumin in Urine______Drug Habit_______

Nervous Trouble_____Attempted Suicide_____Heavy Drinking Habit______

Motion Sickness Requiring Drugs______Military Medical Discharge_______

Physical Condition:_____________________________________________________

Height:______Weight: _______Eye Color:________Hair Color:________

Physical Restrictions (if any): Yes_____No_____

If "yes" please explain: _________________________________________________

Blood Type (If known): _________________________________________________

TRAINING INFORMATI0N

CPR: _______ Date of Class:___________

First Aid:__________ETT:_______EMT:______Other:_____________________________

Other Current Certificates: ___________________________________________________

Other training which may be valuable to the Search and Rescue Team (i.e., heavy rescue, wilderness survival, etc.): __________________________________________________

I thereby certify that all the information given herein is current and truthful to the best of my knowledge; furthermore, I agree to follow, if accepted, all rules, regulations, and bylaws set forth by this organization.

Signed:_______________________________________________Date:________________

I, ________________________________________________ do hereby acknowledge the following:

1) that Kodiak Island Search and Rescue, Inc., is a non-profit corporation formed for the purpose of assisting persons lost or in distress in the wilderness;

2) that membership in Kodiak Island Search and Rescue confers the benefit of training, in rescue and search techniques including, but not limited to, mountain climbing, rappelling, and ice climbing;

3) that search and rescue effectiveness often requires land, sea, and air travel in unfavorable and dangerous weather and light conditions;

4) that the activities of the organization often involve inherent danger to the life, limb, and property of organization members.

WHEREFORE, in consideration of the above and being admitted to membership in Kodiak Island Search and Rescue, I AGREE for myself, my heirs, executor, administrators, and assigns to the following:

1) that I expressly assume the risk of danger to my life, limb, or property arising from all activities engaged in by myself with Kodiak Island Search and Rescue, Inc.;

2) that neither Kodiak Island Search and Rescue, Inc., nor any of its officers or members shall be held liable for any negligence implied or otherwise, or personal injury, or death, or property loss or damage suffered or sustained by myself in connection with or arising out of or resulting from any organization activities;

3) that it is my express intent and purpose to bind myself, my heirs, executors, administrators, and assigns by executing this agreement;

4) that it is my understanding that the provisions stated above shall constitute a PERMANENT WAIVER of all rights of action arising from and during my membership in Kodiak Island Search and Rescue Inc..

SIGNED _______________________________ this _______day of __________ 200__.

WITNESS ________________________________WITNESS___________________________

SWORN AND SUBSCRIBED before______________________ a Notary Public.

for the state of Alaska, this _____________day of______________200__.

Notary Public:________________________________

My commission expires:________________________