PEEKSKILL COMMUNITY VOLUNTEER AMBULANCE CORPS
Home
About Us
Membership
Application
Adult Corps Application
Contact
Events
Request EMS Coverage
CPR
Donations
Incidents
Photo Gallery
St. Patrick's Day Parade 2022
August 23rd HQ Cleaning
August 14th Duty Crew
August 10th Peekskill Police Department Youth Academy
August 10th Busy day
August 6th Peekskill High School Group Tour
August 6th National Night Out
August 3rd Hudson Valley Exposition
July 27th Peekskill Summer Sounds
July 27th Donation to Members
July 21st Mountain Bike Race
July 21st Italian Feast
July 20th - Italian Feast
July 19th - Italian Feast
July 18th - Italian Feast
July 17th - Italian Feast
Saturday Night Volunteers July 13, 2019
Parade July 4, 2019
Yorktown Structure Fire
June 30, 2019
Emergency Services Trailer Operations and Safety Program June 29, 2019
June 27, 2019
Parade Prep June 26, 2019
Girl Scout Troop 1395 - June 25, 2019
Stop the Bleed - June 24, 2019
Fat Tire Festival - June 9, 2019
Be First Boxing - June 9, 2019
Youth Corps Training - June 8, 2019
American Legion - June 8, 2019
Rig Checks - June 7, 2019
Summer Cleaning - June 4, 2019
Autism Awareness Month
EMS Week 2019
St. Patrick Day Parade
Peekskill River Front
Dinner Dance
Polar Plunge
City Hall Drill- November 1st, 2014
Indian Point Drill
Proclamation from The City of Peekskill
50th Anniversary
Application for Membership
Please provide the requested information below, or you can download the forms,
Adult Application
, fill it out and send it back to us.
You must be 18 years or older to be in Adult Corps
Adult Corps
Personal Information
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date of Birth (mm/dd/yyyy)
*
Email
*
Home Phone
*
Cell Phone
*
School or Employer Information
Employer or School Name
*
Employer or School Address
*
Line 1
Line 2
City
State
Zip Code
Country
Work Phone
*
How Long There
*
Less than 1 month
1-6 months
1-3 years
Over 3 years
Never
Emergency Contact Information
Name of Person to Notify in Case of Emergency
*
Relationship
*
Phone
*
References
Please give only references that you have known for at least 5 years.
(No family members, or Peekskill Ambulance Corps members)
1st Reference
1st Reference Name
*
First
Last
1st Reference Address
*
Line 1
Line 2
City
State
Zip Code
Country
1st Reference Phone
*
2nd Reference
2nd Reference Name
*
First
Last
2nd Reference Address
*
Line 1
Line 2
City
State
Zip Code
Country
2nd Reference Phone
*
How did you hear about us?
*
Website
Facebook Page
Google search
Street sign
Referred to by current Member
By who were you referred to PCVAC?
*
Driving Information
Do you drive?
*
Yes
No
Has your license been suspended or revoked?
*
Yes
No
If yes, License Number
*
If yes, please explain
*
Limitations
List any physical limitations, if any.
*
Background Information
Have you been convicted of a crime, other than traffic violations?
*
Yes
No
Have you ever been a member of PCVAC or any other ambulance agency?
*
Yes
No
If yes, which agency?
*
Training or Experience
Do you have any of the following?
Have CPR Certification?
*
Yes
No
Have First Aid Certification?
*
Yes
No
Have EMT Certification?
*
Yes
No
Please list any others, if any
*
Declaration
I declare, subject to the penalties of perjury, that the above statements made in this application have been examined by me and to the best of my knowledge are true and accurate.
*
Yes
Full Name
*
Date
*
Submit
Home
About Us
Membership
Application
Adult Corps Application
Contact
Events
Request EMS Coverage
CPR
Donations
Incidents
Photo Gallery
St. Patrick's Day Parade 2022
August 23rd HQ Cleaning
August 14th Duty Crew
August 10th Peekskill Police Department Youth Academy
August 10th Busy day
August 6th Peekskill High School Group Tour
August 6th National Night Out
August 3rd Hudson Valley Exposition
July 27th Peekskill Summer Sounds
July 27th Donation to Members
July 21st Mountain Bike Race
July 21st Italian Feast
July 20th - Italian Feast
July 19th - Italian Feast
July 18th - Italian Feast
July 17th - Italian Feast
Saturday Night Volunteers July 13, 2019
Parade July 4, 2019
Yorktown Structure Fire
June 30, 2019
Emergency Services Trailer Operations and Safety Program June 29, 2019
June 27, 2019
Parade Prep June 26, 2019
Girl Scout Troop 1395 - June 25, 2019
Stop the Bleed - June 24, 2019
Fat Tire Festival - June 9, 2019
Be First Boxing - June 9, 2019
Youth Corps Training - June 8, 2019
American Legion - June 8, 2019
Rig Checks - June 7, 2019
Summer Cleaning - June 4, 2019
Autism Awareness Month
EMS Week 2019
St. Patrick Day Parade
Peekskill River Front
Dinner Dance
Polar Plunge
City Hall Drill- November 1st, 2014
Indian Point Drill
Proclamation from The City of Peekskill
50th Anniversary