Adult Volunteer Membership Application

Adult Volunteer Application

Please complete this form to apply as an adult volunteer.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Why do you want to volunteer with our agency?
Which areas are you interested in volunteering?
Please select your availability
Are you CPR Certified?
Upload CPR Card

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Are you EMT Certified?
Upload EMT Card

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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:
Please list any relevant skills, certifications, or languages spoken
Reference Name 1
Reference 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference Name 2
Reference 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference Name 3
Reference 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any medical conditions we should be aware of?
Please specify medical conditions
How did you hear about PVAC?
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 the 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.
Applicant Signature
Date of signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Adult Volunteer Application