Youth Corps Application

Application for Membership

Please provide the requested information below, or you can download the forms, Youth Application, fill it out and send it back to us.

Youth 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 *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Employer or School Phone Number *

How long there? *

Parent or Guardian Info

Parent or Guardian's Name *

First

Last

Parent or Guardian's Phone Number *

References

1st Reference Name *

First

Last

1st Reference Address *

Line 1

Line 2

City

State

Zip Code

Country

1st Reference Phone Number *

1st Reference Email *

2nd Reference Name *

First

Last

2nd Reference Address *

Line 1

Line 2

City

State

Zip Code

Country

2nd Reference Phone Number *

2nd Reference Email *

How did you hear from us? *

If Referred by a Current Member, who? *

Limitations

Please list any 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? *

Have CPR Certification? *

Yes No

Please list any others, if any *

Have First Aid Certification? *

Yes No

Please make sure all above information is correct. Some additional information is required, such as parent or guardian permission.
Please hit submit button below and we will contact you shortly. Thank you.

Submit

Application for Membership

Youth Corps

Personal Information

School or Employer Information

Parent or Guardian Info

References​

Limitations

Background Information

Contact Us

References