Please provide the following information:

NSP Number:

Radio Number:

Secondary

E-Mail Address:

Last Name:

First Name:

Address:

State & Zip:

City:

Phone Numbers:

Primary

E-Mail Address:

              Home:

              Work:

              Cell:

Additional Tubes:

Please list your name or the name of any eligible family members for each additional tube below.

Be sure to select a "Ski" or "Snowboard" choice for each additional tube you desire.

Note: If the tube is for you, please list your name.

Weekdays:

          Would you be interested in working any weekdays? (Paid position).

Note: If you select yes, someone will contact you about any available positions.

Tube #2:

Tube #4:

Tube #1:

Tube #6:

Tube #3:

Tube #5:

Ski

Ski

Ski

Ski

Ski

Ski

Snowboard

Snowboard

Snowboard

Snowboard

Snowboard

Snowboard

Guest Pass Vouchers

If you checked Guess Pass Vouchers, proceed to "Boot Barn Ski/Snowboard Storage:"

Age:

Season Pass #1:

Season Passes for up to two individuals

For a seasons pass, please provide the full names of family members:

Season Pass #2:

Age:

          One guest pass voucher will be earned for every shift worked, that may be used by family or friends.

          Note: These vouchers do not have to be used the same day that they are issued, and can be used for

          any full ski session during the current year.

          Season passes are for two immediate family members. Eligible children are as follows: Those who are

          18 years old or younger (24 years old if enrolled as a full time student in college).

          Please select one:

Guest Passes:

          Each patroller shall have the option of receiving either a guest pass voucher for each shift worked or

          receiving season passes for two (2) eligible immediate family members (spouse and child or 2 children).

None

None

None

None

None

None

Night Duty:

Retention Incentive Program:

          Are you entered into the Retention Incentive Program (R.I.P.)? (patrollers with 20 or more years of service)

YES

NO

Boot Barn Ski/Snowboard Storage:

          Please select your Ski/Snowboard storage "Tube(s)".

          There is no cost for your first tube.

Patroller Tube (free):

Ski

Snowboard

Member Information Form

2020 - 2021 Season

All photos and logos on this web site are copyright protected. ©

Montage Mountain Ski Patrol - 1000 Montage Mountain Road - Scranton, Pennsylvania 18507

Name:

Phone Number:

Please provide an emergency contact:

Note: This information will remain private with the patrol and not be published.

EMS Number:

Additional Boot Barn Ski/Snowboard Storage:

          Please select your additional Ski/Snowboard storage "Tube(s)".

          Additional tubes cost $5.00 per "Tube".

Field Format Example: EMR 123456

Please include your EMR, EMT, Paramedic or PHRN designation along with

your 6 digit number.

Field Format Example: (570) 123-4567

Field Format Example: (570) 123-4567

Incident Command Training (ICS - NIMS) Certification Completions:

Field Format Example: 023-123456

Field Format Example: 12 or 123

YES

IS-700.(A):

YES

NO

NO

IS-100.(B):

YES

NO

IS-200.(B):

Field Format Example: (570) 123-4567

Field Format Example: (570) 123-4567

If you only use a cell phone please also enter your cell number for your home phone number!

Please select your two "Duty Night" choices from the drop down menu below.

Please note:

     R.I.P. Patrollers: Please select either:  10 weekend days  or  two duty nights.

     Day Patrollers: Please scroll to the bottom and select "Day Patroller".

     If you DO NOT make a selection your night choice selection defaults to:

     "Assign me to any night duty as needed!"

No

Yes

Night Duty Choice:

YES

My NSP membership dues have been paid in full:

NO

Have you renewed your 2020-2021 NSP Membership Dues?

My Personal Information: