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Glenwood Pochuck Volunteer Ambulance Corps
Membership Application
Membership Classification:
Jr. Cadet (14-15 Yrs)
Cadet (16-18 Yrs)
Member (18+ Yrs)
EMS Task Force (18+ Yrs)
Associate (Non-Riding)
Demographics:
Full Name *
Preferred Name
Gender *
Male
Female
Other
Date of Birth *
Place of Birth *
Current Street *
Current City *
Current State *
ZIP Code *
Municipality of Residence *
Contact Information
Email *
Phone *
Phone Carrier *
Verizon
T-Mobile
AT&T
Other
Certifications
(Training provided)
CPR BLS
First Aid
NJ EMT-B
NREMT-B
Paramedic
CEVO/EVOC
Life Guard
ICS 100
ICS 200
NIMS 300
NIMS 400
NIMS 700
NIMS 800
Other Certifications
Employment Information
Employer Name
Employer Address
Supervisor Name
Contact Number
References
Reference 1:
Name
Phone
Reference 2:
Name
Phone
Reference 3:
Name
Phone
Experience
Previous EMS / Military Experience
Questionaire
Have you had any motor vehicle accidents in the past 3 years?
Has your Driver's License been revoked or suspended in ANY state?
Have you ever been convicted of a criminal offense?
Have you ever received a traffic violation?
Have you ever used illegal drugs?
Are you currently using illegal drugs?
Are you currently taking prescription medication on a regular basis?
Do you have any physical or mental disability that may prevent you from performing job duties?
Do you have any past medical history that may prevent you from preforming job duties?
Are you unable to lift more than 50lbs
If you answered yes to any of the above, please elaborate below.
Availability
Please indicate when you're available to volunteer. Shifts are broken up into 12 hour shifts on a weekday, 6 hours if you're under 18 years old and 10 or 12 hour shifts on a weekend.
Shirt Size *
XS
SM
M
LG
XL
2XL
3XL
4XL
Warning!
You are signing up as a minor! A parent or legal guardian will need to sign an authorization form that will be sent to your email.
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Email: info@gpvac.org
Mailing: Glenwood Pochuck Volunteer Ambulance Corps. Inc. P.O. Box 241 Glenwood, NJ 07418
1 Drew Mountain Rd. Vernon, NJ 07861