Katonah Bedford Hills Volunteer Ambulance Corps

Volunteers in Spirit - Professionals in Service

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)*			YesNo
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?*			DaysNightsBoth
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?*			YesNo
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?*		NoYes
If Yes, agency/organization where you took your course and the date

Has your license ever been suspended or revoked?*		NoYes
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?*	NoYes	If so, date of offense
Signature*		Date

In an emergency, dial 911.
Non-emergency: 914.232.5872
membership@kbhvac.org

Professional media inquiries: 914.815.8280

Mailing address:
Post Office Box 43
Katonah, NY 10536

Physical location:
160 Bedford Road
Katonah, NY 10536

Designed and built by Shero