New Membership 2020-2021
Please complete the form below to become a member in Flying Samaritans, CSUF.

Requirements of Membership:
1. Membership (*Please look at our website for the links*):
- Regular Membership (Annual Membership + Tshirt): $40
- Premium Membership (NEW Annual Membership + Scrubs): $60
- Renew membership (Annual Membership): $30
- Scrubs Only: $30
2. Attendance of 2 clinics or events per year
3. Attendance at 2 general meetings per year

*Please note that memberships are non-refundable. We are excited for you all to be part of the Flying Samaritans.*
Email address *
First Name *
Last Name *
Date of Birth *
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Student ID# *
Please provide your CSUF student ID#. If not CSUF student please enter "0".
What sparked your interest in Flying Samaritans? *
Please, in a short essay response, share with us your reasons for joining our organization.
Citizenship *
Spanish Proficiency Level *
License Professional *
Please select all that apply, and prepare to prove license at first clinic.
Required
Local Address *
Permanent Address *
Home Phone Number *
If not applicable please respond with "n/a".
Cell Phone Number *
Major *
Please share with us your focus of study at CSUF.
Expected Year of Graduation *
Emergency Contact #1 *
Please provide us the name and phone number of the person we should contact in case of an emergency.
Emergency Contact #2 *
Please provide us the name and phone number of the person we should contact in case of an emergency.
Date Submitted *
MM
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DD
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YYYY
Waiver of Liability *
I, as a member of Flying Samaritans, CSUF, hereby indemnify and hold the Flying Samaritans at CSUF and each and every member thereof, harmless from and against all claims, liabilities, damages, personal injuries, or any and all other damages arising from or in connection with my participation or conduct in or for on behalf of Flying Samaritans at CSUF. I understand the potential consequences that my result and any unavoidable risks involved with my activities pertaining to the Flying Samaritans at CSUF in Mexico.
Required
Digital Signature *
By typing your name below you are confirming that all information on this form is complete and accurate, and accepting all responsibilities associated with membership in Flying Samaritans at CSUF.
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