CSMT Application If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Thank you for your interest in the Community Services Massage Team. Please complete this form. This application may also be returned via USPS by printing the file located here, completing it and sending it to: AMTA-NY Chapter Office, 167 Chamberlain Rd., Honeoye Falls, NY 14472 Reminder - All CSMT Volunteers MUST have a Code of Conduct on File at the National Office as a Chapter Volunteer. Follow this link to complete the Code of Conduct. When you click on the link you will need to log on with your National AMTA login information. After clicking on the link, check the box for Chapter Volunteer. Contact CSMT Chair,David DeLucia, at CSMT@amta-ny.org with any questions. First Name * Last Name * Do You Have AMTA Insurance (this is a requirement to participate)? * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * County * Select One Albany Columbia Essex Hamilton Montgomery Rensselaer Saratoga Schenectady Schoharie Warren Washington Cayuga Fulton Herkimer Madison Oneida Onondaga Oswego Dutchess Greene Orange Putnam Rockland Sullivan Ulster Westchester Clinton Franklin Jefferson Lewis St. Lawrence Bronx Kings Nassau New York Queens Richmond Suffolk Broome Chemung Chenango Cortland Delaware Otsego Tioga Tompkins Allegany Chautauqua Erie Genesee Niagara Orleans Wyoming Livingston Monroe Ontario Schuyler Seneca Steuben Wayne Yates AMTA-NY Unit (if you know it) Select One Capital District Northern NY Hudson Valley NYC/LI Southern Tier Western Finger Lakes Western NY Central NY Home Phone Work Phone Cell Phone Email * Preferred Method of Communication Email Text Voice Call AMTA Member # NYS License # * Do you wish to participate as a Community Outreach Member? * YesNo Do you wish to participate as an Emergency Responder? * YesNo Have you ever worked with an emergency response team/organization? * YesNo If yes, in what capacity? Have you attended CSMT trainings? * YesNo If yes, when? Do you own your own massage chair? * YesNo In the event of an emergency please list a contact: Name * Phone number * Email Relationship * WAIVER AND RELEASE I represent that I am physically fit, that I am medically able to participate, and that I have no condition or other restriction (including use of medication) that would limit my participation in the Community Service Massage Team Emergency Response or Outreach Division. I understand and agree that I participate at my own risk. I HEREBY RELEASE, WAIVE, AND FOREVER DISCHARGE ANY AND ALL CLAIMS AGAINST THE AMERICAN MASSAGE THERAPY ASSOCIATION, ITS CHAPTERS, DIRECTORS, OFFICERS, VOLUNTEERS, STAFF, REPRESENTATIVES, AND SUCCESSORS (COLLECTIVELY, “AMTA”) FOR DEATH, INJURY, LOSS AND ANY AND ALL DAMAGES WHICH I OR MY HEIRS, SUCCESSORS, ASSIGNS, AND REPRESENTATIVES MAY SUSTAIN AND/OR SUFFER IN CONNECTION WITH MY PARTICIPATION IN THE COMMUNITY SERVICE MASSAGE TEAM EMERGENCY RESPONSE OR OUTREACH DIVISION ACTIVITIES. I understand that AMTA or its representatives have the right to refuse or discontinue my participation at any time in their sole discretion. I consent to allow any audio, photos, videos or other images taken of me at the event to be used by AMTA or its agents, as it wishes, without compensation or restriction. I represent that I am at least 18 years old. Follow this link to complete the Code of Conduct. Signature - Please type your full name * Today's Date *
