Nyack EMS Adult Volunteer Application Request for Membership

About You

Name

First Last

Email*

Enter Email Confirm Email

Date of Birth

Address

Street Address City State ZIP Code

Home Phone

Cell Phone*

Work Phone

Employment Information

Occupation/Employer

Employer Address

Employed for how many years

May we communicate with your employer about your application?

Yes
No

Personal References

Provide three verifiable personal references whom you have known for at least two years:

Reference #1 Name*

Reference #1 Phone*

Reference #1 Address

How long has Reference #1 known you?

Reference #2 Name*

Reference # 2 Phone*

Reference #2 Address

How long has Reference #2 known you?

Reference #3 Name*

Reference #3 Phone*

Reference #3 Address

How long has Reference #3 known you?

About You

Common tasks ambulance volunteers perform include but are not limited to: • Lifting and carrying ambulance equipment • Moving patients horizontally while lifting • Operating oxygen equipment • Operating electronic equipment such as a defibrillator which may emit electromagnetic waves

Is there any reason you may not be able to carry out the functions above?

Yes
No

If yes, Explain

Do you hold a current valid NY State driver's license?

Yes
No

If yes, what class?

License Expiration Date

Have you ever been convicted of a felony?

Yes
No

Please explain: Did you receive a certificate of relief from disability?

A Few Final Questions

Why do you want to join Nyack Community Ambulance Corps?

How did the corps come to your attention?

Do you have any experience in emergency medical care?

Yes
No

If yes, list all pertinent certifications:

List your general availability for duty:

Consent*

I agree

I certify by typing my name below that all of the information that I have provided is true to the best of my knowledge; I give permission to Nyack Community Ambulance Corps to do a personal check on the information provided

Your Name Here*

First Last

Electronic Signature/Type Name*

Prior to submitting, please check to see that all required fields, marked with a red asterisk (*) are filled in. Thank you!

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Emergency? Dial 9-1-1

Adult Volunteer Application

About You

Employment Information

Personal References

About You

A Few Final Questions

Emergency? Dial 9-1-1

Contact Us

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