A.E.M.B.A. Mt. Bike PATROL
Patroller Application

Print this page from your browser and type or legibly fill in the following information:

Name:

Street Address: ________________________City______________________State________, Zip: _______

Phone: ( ) ___________Work Phone: ( )__________________

Date of Birth: _______________

Age: ____________e-mail:_______________________________________

Patroller classification which you are applying for: New____ Renewal_______

Summarize your first aid background (if any) below, with classes taken, cards issued, cards current (enclose copies), medical experience, CPR classes, instructor experience....etc.

Please summarize any related activities pertaining to Mt. Bike Patrol below (clubs, instructing, mountaineering, search and rescue, climbing...etc):

Please summarize your motivations for wanting to become a patroller and areas you wish to patrol below:

I hereby apply for membership in the AEMBA Mt. Bike Patrol . I also understand that fees paid by me for application and registration may not be refundable if I discontinue the AEMBA

Signature of applicant:__________________________________________Date:_______________________________ __

Mail the completed form with membership fee to:

Dean Leshock

30 Lewis DR

Ruckersville, VA 22968