Elkhorn Area Fire-Rescue Explorers

Membership Application

 

 

 

Please fill out all information accurately.  Signatures must be accompanied by an adult parent for all applicants under the age of eighteen (18).  If available, please enclose a copy of your drivers’ license. There will be a $10.00 per year dues fee which must be applied also.

 

 

 

Name _________________________________________________________________

                              Last                                              First                                               Middle

 

Address ________________________________________________________________

                                                           Street                                                                         Town   

 

 

Phone Number (      ) __________-___________         

 

 

Date of Birth ______________        Age ________________    Gender______________

 

 

Grade______________ 

 

 

Blood Type (if known) _____________________

 

 

Emergency Contact __________________________   Relationship__________________

 

Address_________________________________________________________________  

 

Phone Number #1_______________________ Work Number______________________

 

 

 

Applicant Signature_______________________________   Date________________

 

Parent Signature __________________________________  Date________________

 

Advisor Signature ________________________________   Date_________________