SARNAK Membership Application
Print and Mail to:
SARNAK
Search and Rescue of the Northern Adirondacks
P.O. Box 1116
Saranac Lake, NY 12983
USA
NAME ___________________________________ DATE OF BIRTH __________
ADDRESS _______________________________________
_________________________________________________
TELEPHONE(s) home _____________________ work ____________________
alternate ________________ cellular_______________ pager __________________
HAM RADIO CALL SIGN _______________ E-MAIL ________________________
DRIVER’S LICENSE # & STATE____________________________
EMERGENCY CONTACT name ________________________________ telephone _________________________
Current Employer/School:___________________________________________________
Contact Person & Phone Number:___________________________________
________________________________________________________________________
CURRENT/MOST RECENT PREVIOUS EMERGENCY RESPONSE AFFILIATIONS
1. Organization, ________________________________ Position Held_______________
Contact Person, ____________________________Phone Number __________________
2. Organization, ________________________________ Position Held_______________
Contact Person, ____________________________Phone Number __________________
3. Organization, ________________________________ Position Held_______________
Contact Person, ____________________________Phone Number __________________
CERTIFICATIONS AND EXPIRATION DATES, if applicable enter certification number. (Please provide photo copy of current certification credential)
SAR: DEC Wildlands Search: Basic____________ Crew Boss ____________ Other____________
ICS: 100 200 300 400 Other____
First aid: CPR______________ (indicate level and agency) First Aid______________ (indicate agency)
Red Cross When Help is Delayed______________ Red Cross Lifeguard Training ______________
NYS Certified First Responder______________ NYS EMT________________________ (indicate level)
WFA_________ WAFA___________WFR___________ WEMT__________
NSP Outdoor Emergency Care______________ Other______________
Additional equipment available for personal or team use associated with team activities: (e.g.: boat, HAM or CB radio, transport trailer, generator, pump, chain saw, rescue or evacuation equipment, ropes, snowshoes, skis, scuba, extra gear, etc.):
Wilderness / SAR background, or special skills (e.g.: professional knowledge, second language, skills instructor, membership in outdoor groups, related avocations, etc.):
Annual Membership Dues are $10, payable at the time of application.
I agree to uphold the Bylaws and Standard Operating Guidelines of SARNAK. I agree that I will become DEC Wildlands Search, certified, or acceptable equivalent, within one year of membership. If there has been no certification course available within that time, I agree to become certified at the earliest opportunity.
Signature:_____________________________ Date_________________
Official use only
Date voted to membership _____________ Date dues paid ________ Received by:
SARNAK
Search and Rescue of the Northern Adirondacks
Release, Hold Harmless and Indemnification Agreement
The undersigned, for an in consideration of being considered for membership, hereby authorizes the release of information and documents, so as to verify the information set forth on the application for membership.
The undersigned, hereby agrees to hold harmless and indemnify, SARNAK, its officers, agents, employees and members, from any consequences from attempting to or obtaining, the information and documents.
SARNAK shall not disseminate any information or documents to any other person or entity and shall use the information and documents for the sole purpose of verifying the information provided on the application.
Dated
Signature
A motion from the ad-hoc committee on membership
We Motion That:
1. As per Article IV of the By Laws, a standing membership committee be established.
2. As per Article IV of the By Laws any application submitted for membership must be sent to the Membership Committee for review.
3. The membership application shall be amended to include current employer and previous and current public safety, SAR, fire service etc. affiliations, when affiliated, (from-to dates), positions held, with contact person and phone number in each organization. A reference release form shall be established, and shall be submitted with the Application for Membership form. Applicant will provide photocopies of all current certifications.
4. The process that the membership committee shall undertake as part of every applicant’s review will include, but not be limited to, verifying current employment and all public safety, SAR, fire service, etc contacts provided by the applicant on the membership application to confirm affiliation data.
5. The results of these verifications shall be included as part of a report by the membership committee to the full membership. The applicant shall be given an opportunity prior to the final report to clarify any discrepancies or unfavorable references.
6. As part of the above mentioned report, the membership committee will also provide a recommendation on an applicant’s membership, with explanation, prior to the vote on the applicant’s membership.
Note for discussion: Employer contact is intended only to verify information on the application. If the applicant claims employment, but would rather we did not contact the employer, other means of proof could be provided.
To be implemented 1/1/06
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A member ship committee has been established to handle application processing.
Brogan
Premo
Buzzell
Reference Release has been developed.
SOG Review under way.