Junior Volunteer Membership Application

Junior Membership Application
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Are you CPR certified?
Upload CPR Card

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Do you have any other relevant certifications/certificates?
Other certifications/certificates

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Do you have a NYS Photo ID?
Upload NYS Photo ID

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Do you belong to any other organizations?
List any other organization you belong to:
Have you ever been turned down by an organization?
Please explain why you were turned down:
Have you ever been forced to leave an organization?
Please explain why you were forced to leave:
Do you have any medical or physical conditions?
Please list all medical or physical conditions:
Are you currently attending a school?
What’s your current school year and what school do you attend? (Add your major if applicable)
Please list any special knowledge or skills you may have (i.e mechanics, carpentry, computers)
I understand that the Philipstown Volunteer Ambulance Corps. will use the information provided herein and other pertinent information to conduct a background investigation as part of the application process. Any false or misleading statement made on the application will result in automatic rejection of the application. I further understand that a full examination including substance abuse screening is required for admission as a member. I authorize Philipstown Volunteer Ambulance Corps. to contact all necessary persons or organizations in order to conduct a complete investigation. I agree to keep all patient information confidential.
Is the Applicant less than 18 years of age?
Applicant Signature
Date of Applicant Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Parent or Guardian for minor applicant
Date of Parent/Guardian Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name

First NameLast Name
Parent/Guardian phone number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Junior Membership Application