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Glenwood Pochuck Volunteer Ambulance Corps
Jr. Cadet (14-15 Yrs)
Cadet (16-18 Yrs)
Member (18+ Yrs)
EMS Task Force (18+ Yrs)
Full Name *
Date of Birth *
Place of Birth *
Current Street *
Current City *
Current State *
ZIP Code *
Municipality of Residence *
Phone Carrier *
Previous EMS / Military Experience
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Has your Driver's License been revoked or suspended in ANY state?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.
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 *
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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Medical Release Form
Glenwood Pochuck Volunteer Ambulance Corps. Inc. P.O. Box 241 Glenwood, NJ 07418
1 Drew Mountain Rd. Vernon, NJ 07861
Proudly Affiliated with RWJBH Medical Control