APPLICATION FOR MEMBERSHIP                                                    PAGE 3 HERBERTSVILLE FIRST AID SQUAD

DO YOU HAVE ANY HANDICAPS/MEDICAL ISSUES THAT WOULD PREVENT YOU FROM PERFORMING DIFFERENT ASPECTS OF FIRST AID AND/OR GENERAL MEMBERSHIP?                                                     

IF SO, PLEASE EXPLAIN:                                                                                                      

HAVE YOU EVER BEEN CONVICTED OF A CRIME ?                                                      

PERSONS TO BE NOTIFIED IN CASE OF EMERGENCY:

1.                                                                                                                                               

2.                                                                                                                                               

WHAT MADE YOU BECOME INTERESTED IN JOINING THE FIRST AID SQUAD ?

                                                                                            SIGNATURE OF APPLICANT

                                                                                            DATE: