Please note:  Commitments of the Riding Member include, but are not limited to:

-  All riding members must attend Tuesday night meetings and training drills at 7:30 pm in accordance with the by-laws of the Lewisboro Volunteer Ambulance Corps.

-  A minimum of 48 riding hours per month.

-  All riding members are required to participate in Corps functions

-  All riding members are required to attend an Ambulance Orientation and a Policies and Procedures Orientation with an appointed officer, and must be familiar with such, before they are permitted to ride with a duty crew.

-  All Riding members must maintain current certifications in American Heart
Association CPR and First Aid for the Healthcare Professional.

You are required to complete the American Heart Association CPR and First Aid courses for Healthcare Providers prior to riding with a duty crew. Our instructors will provide you with the required training. These certifications must be maintained in order to remain active in riding status and to participate in LVAC functions.

Please fill in each of the following fields and click "Submit" when complete. Please note that all fields are required to be completed.

Any Questions? Please call the Captain's Line at: (914) 763-9633 or eMail us at: Lewisborovac@aol.com

Your Name

Your Address  

Your eMail  

Home Phone  

Business Phone  

Cell Phone  

Date of Birth  

Age 

Male      Female

Occupation  

Social Security Number  

Have you had any First Aid, CPR, or other healthcare training?  Yes     No
If Yes, please explain:  

If you have any current certifications, please list the type of certification, expiration date and ID#:

Course     Expiration Date  
ID#  
 
Course     Expiration Date  
ID#  

Although not a requirement, would you be interested in furthering your medical training and becoming a New York State Certified Emergency Medical Technician (EMT)?  Yes     No

List people you know who are currently members of LVAC:

Member  
Member  
Member  
Member  

REFERENCES: List three people we may contact as a reference (other than relatives or family members), preferably from an organization you belong or have belonged to:

Name       Phone  
Relationship  
 
Name       Phone  
Relationship  
 
Name       Phone  
Relationship  

What are your hobbies or personal interests?

Briefly explain why you chose to apply for membership in the Corps:

Have you ever been a member of any local, civic, church, or other volunteer organization?

Please list the times and days you would be available to volunteer:

As a riding member of LVAC, it may be necessary to perform a variety of tasks during the course of a typical emergency call, including walking on rough or uneven ground, gripping with both hands, climbing stairs, kneeling, crouching, lifting and running a short distance. Do you have any physical disabilities or limitations which would prevent you from participating in any of the above activities?    Yes      No

If yes, please explain:

At any time have you ever suffered from or experienced symptoms of: Chronic back pain, sciatica or other disorder of the back, neck or spine; near fainting or fainting episodes, vertigo or seizures?       Yes      No

If yes, please explain:

Do you have any other medical conditions or symptoms not mentioned above or do you take any medication which would make it difficult or dangerous for you to drive, operate equipment or ride on the ambulance?

       Yes      No

If yes, please explain:

Have you ever been convicted of a crime?      Yes      No

If yes, please explain:

Have you ever suffered from or been treated for alcohol or drug abuse?

Yes      No

If yes, please explain:

* * * * *

The above information is for use solely by the Board of Directors of the Lewisboro Volunteer Ambulance Corps in assessment of an applicant's eligibility for membership as well as their ability to undertake the tasks necessary to be a riding member. Answering yes to any of the above questions does not necessarily disqualify you from being accepted as a riding member of the Corps. If deemed appropriate, you may be required to provide a physician's statement confirming your ability to perform necessary tasks in a safe and effective manner. This information is considered confidential and will not be shared with the general membership or any outside agency, but will be retained by the Corps as part of your personnel file.

* * * * * *

The information I have provided in this application is true and accurate to the best of my knowledge. I understand that any false information shall be reason for my immediate dismissal from the Lewisboro Volunteer Ambulance Corps. I also agree that, if accepted by the membership, I will, at all times, obey the by-laws, operating rules and policies of the organization and perform in an appropriate manner which is beneficial to the Corps.  (By completing your name and the date, you are signing the application.)

Signed:  

Date:  

 
 
 
© 2013 Lewisboro Volunteer Ambulance Corps
All text and photos are the property of the Lewisboro Volunteer Ambulance Corps
and may not be reproduced without written permission.
All rights reserved.