Adult Corps Application

PEEKSKILL COMMUNITY VOLUNTEER AMBULANCE CORPS

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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 *

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? *

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

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Contact Us

* Indicates required field

Name *

First

Last

Email *

Comment *

Submit

Peekskill Community Volunteer Ambulance Corps
1427 Main St.
Peekskill, NY 10566

Created by Genner Villon