Katonah Bedford Hills Volunteer Ambulance Corps
Volunteers in Spirit - Professionals in Service
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Volunteer Application
Click to Download the PDF Form
Step 1: General Info
*required
Name
*
Date of Birth
*
Address
*
City, State Zip
*
Home Phone
*
Work Phone
Cell Phone
Cell Phone Carrier
Email
*
TShirt Size
Where did you hear about us?
Driver's License ID #
*
Name of Employer
Address of Employer
Under 18 Years of Age? (All Junior Corps members must have a
parent or legal guardian sign)
*
Yes
No
Step 2: Previous Affiliations
Agency Name/Address
Contact Name
Contact Telephone Number
Step 3: Availability
The Corps asks that you're available to respond for six hours
a week, either day or night; when would you be able to
respond?
*
Days
Nights
Both
If you are unable to respond to the Corps within the required
5 minutes, would you be willing to stay at our headquarters
or within close proximity to the Corps during your
shift?
*
Yes
No
Please explain why you would like to be a member of the
Corps:
*
Step 4: References
Please list the names, addresses and telephone numbers of
three non-family character references:
Reference 1
*
Reference 2
*
Reference 3
*
Step 5: Driving Info
Have you ever taken a Defensive Driving course?
*
No
Yes
If Yes, agency/organization where you took your course and
the date
Has your license ever been suspended or revoked?
*
No
Yes
If Yes, explain
Permission for arrest check:
*
Permission to authorize drivers license checks:
*
Please list any accidents over the past 36 months. Note: All
driving records will be verified through insurance companies.
Have you ever been convicted of a felony?
*
No
Yes
If so, date of offense
Signature
*
Date
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