Youth Corp Application

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Youth Corp Application

Please fill out the below information to be considered for Youth Corp membership.

Indicates Required Field

Name:
Street Address:
Apartment:
Town:
State:		NY NJ
ZIP:
Home Phone Number:
Cell Phone Number:
Email Address:
Date of Birth:
Age:
School Currently Attending:		Nanuet HS Clarkstown South HS Pearl River HS Clarkstown North HS
Please list extracurricular activities you are involved in:
Do you have any certifications in CPR/Blood Borne Pathogens/First Aid/NYS Certified First Responder?:		CPR Blood Borne Pathogens First Aid NYS CFR
Have you had any other experience with another Ambulance Corps or Fire Dept?:		Yes No
Please list which agency and dates of membership. If you are no longer a member, please explain why.:
Have you ever been charged or convicted of any violation of the law?:		Yes No
Do you have any impairments that may limit you from being physically active or taking an active role in providing patient care in an emergency situation?:		Yes No
Please explain any impairments:
Have you had any illness or injury requiring hospitalization or medical treatment within the last five years?:		Yes No
Please explain any hospitalizations/medical treatments:
Where did you hear about us?:		School Family Friend Internet Other I saw your building/ ambulances and researched membership
If one of our members encouraged you to join, please consider letting us know who to thank!:

PLEASE REVIEW WITH A PARENT/GUARDIAN

PLEASE READ CAREFULLY BEFORE SIGNING!: I declare that the statements made in the application are true and correct. I understand that any false statements made on this application will result in immediate disciplinary action, or dismissal. I understand that the function of the Yoth Corps. is to aid and assist the Senior Corps, to abide by the Youth Corps. Code of Conduct and any other guidelines set forth by the Youth Corps Line Officers and Advisors. Enter full name after reviewing with parent/ guardian.
Parent/Guardian Name:
Relationship:		Parent Guardian
Emergency Contact Information #1: Please include FULL name, relationship to applicant, cell phone number and home phone number.
Emergency Contact Information #2: Please include FULL name, relationship to applicant, cell phone number, and home phone number.
Submitted:		03/27/2023 0727
Once submitted someone from our Youth Corp membership committee will contact you. Thank you for your interest in joining Nanuet Community Ambulance Corp. Youth Corp

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