Please fill out this form and email a copy of your certification, license or CPR card to: emsangelsmccali@gmail.com
Please provide the following contact information. This information is collected and kept on file with the club secretary and is confidential. At no time will we release, sell or otherwise disclose your information. If you are uncomfortable submitting this online you may email the club secretary at the above address and other arrangements can be made.
First Name Last Name Middle Initial City State/Province Home Phone E-mail
Date of Birth
Choose one of the following options:
New Member Renewal Change of Member Status
What EMS agency are you affiliated with?
Number of years in EMS?
Do you own a motorcycle?
Yes No
Do you have insurance?
Do you have an operator's license?
Enter the make, model, year of your bike in the space provided below.
Enter an emergency contact name in the space provided below.
Enter an emergency contact phone number in the space provided below.
Have you ever ridden with a club?
Enter the name of the club in the space provided below.
How did you hear of EMS Angels?
What are you looking for in a club?
Select any of the following options that apply:
EMT Paramedic CPR First Aid Other