Membership Application

Date of Application:___/___/____

Member information :

Name:___________________________________________________________________ Address:________________________________________________________________

City:_______________________ Zip Code:______________

If San Diego, which area? _______________________

Phone (H):________________ (W):________________ Cell:__________

E-mail:___________________________

SS#:______-______-_______

Birth Date:____-_____-____ Height:________ Weight:________ Hair:________ Eyes:_____

Employer Name & Address:___________________________________________________

Position:________________________ Work Days:______________________ Hours:____

Can you leave work for an emergency rescue? Y  N 

Will you agree to obtain proper full uniform? Y  N 

Will you agree to attend scheduled training? Y  N 

Are you in good physical condition? Y  N 

List any physical limitations:___________________________________________________

List any special training or qualifications:_________________________________________

Have you ever been convicted of a felony? Y N

Do you have any aliases? Y N                            List them here:_______________________

Animal Handling Information:

Check animals you have experience with :

Dogs  Cats  Equine  Birds  Livestock  Wildlife  Sea Animals  Exotics 

specify others: _____________________________________________________

Equipment Available for Rescue Operations:

Trailer                                      Radio Operator                                   Vehicle Type:

2 Horse                                   Call Sign: ________                             Car 

4 Horse                                   Base Station                                     Truck 2WD  4WD 

Stock                                      CB                                                   Winch 

Hitch:                                                                                                   Camper 

Bumper                                                                                               ATV 

5th Wheel 

Travel Trailer 

Driver Lic.#________ Exp.Date__/__/__ Class A? Y  N 

Car Lic.#_________ Trailer Lic.#__________ Truck Lic.#______________

 Level of Membership:

Active  Dues are $24.00/year

Reserve  Dues are $12.00/year

Junior Reserve  Dues are $12.00/year

Auxiliary  Dues are $12.00/year

All dues are collected on July 1st of each year. Members joining mid-term

will pay pro-rated dues, i.e., $2.00/mo for Active, $1.00/mo for all others.

Name of vehicle insurance ________________________________________________

Name of trailer insurance ________________________________________________

Medical Insurance_________________________________________________________

In case of emergency, please notify_______________________________________

Emergency Animal Rescue

 Membership Waiver I, ____________________________ (please print full name), as an Emergency Animal Rescue member, assume full

financial responsibility for and all bodily injury or death that may occur to me personally upon any Emergency Animal Rescue business whatsoever.

I also assume full financial responsibility for any and all damage that may occur to my personal vehicle, trailer or equipment upon any Emergency Animal

Rescue business whatsoever.

Signature_____________________________ Date________________

Parent or guardian (if minor)______________________________

Mail completed application with dues to:

Emergency Animal Rescue

P.O. Box 2462

Ramona, Ca. 92065