H.E.E.T. Horse Emergency Evacuation Team ***MEMBERSHIP APPLICATION*** P. O. Box 2473, Nipomo, CA 93444, 805-466-7457 or 805-264-3422

Name:______________________________________________

Address:____________________________________________

Phone:______________(home)____________________(work)

Email:___________________ DL #____________________

Cell Phone:__________________ Pager:____________________

Occupation: ________________ Hours: ____________________

Job Location: __________________________________________

Available during weekdays for rescues? _____________________

Permission for background check_____(initial)

Equipment (Y/N): Horse trailer____ Size:______________ Type:_____________

CB ___________ Scanner___________ Radio_____________

Area of Interest: _____ Rescue _____ Communications _____ Billeting areas _____ Care & Feeding _____ Education _____ Census/Registration _____ Fund-raising/Donations

I hereby release HEET from liability for injuries sustained by my participation in HEET activities and rescues.

_____I have enclosed a check for $25.00 for annual individual membership dues.

_____I have enclosed a check for $35.00 for annual family membership dues.

Signature: ____________________________

Date: _____________