SCEMS Membership Form
Name
First Name
Last Name
C#
Cortland Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Academic Major
Graduation Semester (Spring/Fall) and Year
Local Address
Home Address
Phone Number
Please enter a valid phone number.
Emergency Contact (Name and Phone #)
Any Known Allergies
Are You CPR and First Aid Certified?
Please Select
Yes
No
Expires soon (this semester)
Are You Certified as an EMT?
Please Select
Yes
No
How did you find out about us?
Please leave name of the member or their position if referred!
Submit
Should be Empty: