Register — Flying Samaritans AZ

✈ Flying Samaritans AZ Flying Samaritans

New Member Registration

Fields marked * are required.

Membership Type

Type *

If choosing the Family Membership, enter the name of the member with the regular membership

Home Chapter

Chapter (where you pay dues) *

Personal Information

First Name *

Last Name *

Address

Street Address *

Street Address 2

City *

State *

Zip Code *

Phone Numbers

Cell Phone

Home Phone

Work Phone

I am bilingual (English/Spanish)

Emergency Contact

Contact Name *

Contact Phone *

Passport and Travel Information — Please list your name exactly as it appears on your passport

Last Name *

First Name *

Middle Name

Sex *

Male Female

Date of Birth *

Weight (lbs) *

Required for aircraft weight & balance

Citizenship *

Passport Number *

Passport Expires *

Professional / Skills Useful to Flying Samaritans — Check all that apply

Medical

Audiologist Medical Doctor Nurse Nurse Practitioner Ophthalmologist Optometrist Pediatrician Physical Therapist Chiropractor Other

Dental

Dentist Dental Assistant Hygienist Other

Support

Pilot Interpreter Helper Other

If you checked "Other" in any category, please describe:

Email Address *

Password *

Minimum 8 characters

Confirm Password *

Next step: After submitting this form you will be asked to read and sign our Release of Liability waiver before your registration is complete.

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