Application for Membership

BEACON VOLUNTEER AMUBULANCE CORPS. INC
Membership (please select one)
AdjunctRiding

Name

Age

Date of Birth

Telephone
Email Address

Home Address

Current Occupation

Employer Name & Address

Has applicant ever been an ambulance corps member?
YesNo
If so, state name and address of ambulance corps:

Are you a certified EMT? YesNo Paramedic? YesNo
If yes, indicate#, date of expiration and state of issue:

Why do you wish to join the ambulance corps?

Please list two character references:

Reference 1 (Name, Address, Phone)

Reference 2 (Name, Address, Phone)

Duty Time Minimum Requirements for active membership:
- Junior Membership will be for applicants from ages 15 to 17. The minimum duty time required is three (3) hours per week in the building.
- Adult Membership will be for applicants with a minimum age of 18. The minimum duty time required is six (6) hours per week. There is also an expectation of the applicant to attend training sessions, meetings, drills, and work details.
Some flexibility is available based on the applicant’s schedule, however attendance is necessary to learn and practice essential skills of patient care, be familiar with our equipment, and test processes, protocols, & procedures
to comply with various federal (i.e. National Incident Management Systems), state (i.e. NYS DOH BEMS), and local requirements.

In lieu of active membership, the Corps is looking for a limited number of adjunct members to fulfill specific agency needs. Please feel free to contact the Corps if you are interested in these positions.

I hereby apply for membership in Beacon Volunteer Ambulance Corps of Beacon, New York. If accepted into this corps, I promise to subscribe to and support the constitutional by-laws of the corps, follow all governing rules and regulations, and conduct myself in a manner becoming a corps member.

Applicant's Signature

If accepted, what is your availability —

Weeknights:

Monday:
6pm-midnightmidnight-6am

Tuesday:
6pm-midnightmidnight-6am

Wednesday:
6pm-midnightmidnight-6am

Thursday:
6pm-midnightmidnight-6am

Friday:
6pm-midnightmidnight-6am

Weekends:

Saturday:
6am-12pm12pm-6pm6pm-midnightmidnight-6am

Sunday:
6am-12pm12pm-6pm6pm-midnightmidnight-6am