Application

Application Instructions

Thank you for taking the time to apply to Larchmont Volunteer Ambulance Corps. Please carefully complete all required sections of the application below. The application will take about 30 minutes to complete.

Upon submitting this application you will be redirected to another page to pay our non-refundable $25 application processing fee.

If you have any difficulties or questions about completing our application please e-mail us.

* Indicates required field

Please upload your resume here *

Max file size: 20MB

Personal Information

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Contact *

Number *

E-Mail *

Last 4 of Social Security # *

Birth Date (mm-dd-yyyy) *

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

References

We require at least two references to complete this application. A personal reference (friend, family, etc) and a professional reference (teacher, employer, coach, etc.) are both required. Your third reference can be either.

Personal Reference Name *

First

Last

Personal Reference Relationship *

Personal Reference Phone Number *

Personal Reference E-Mail *

Professional Reference Name *

First

Last

Professional Reference Relationship *

Professional Reference Phone Number *

Professional Reference E-Mail *

Third Reference Name *

First

Last

Third Reference Relationship *

Third Reference Phone Number *

Third Reference E-Mail *

Supplemental Questions

Below are 8 required short answer questions to help our membership committee learn more about you the applicant. All 8 questions must be completed to submit this application.

1. Why do you want to be a part of Larchmont Volunteer Ambulance Corps? *

2. How did you hear about Larchmont Volunteer Ambulance Corps? *

3. Do you have any previous volunteer experience of any kind, if yes please elaborate? *

4. Do you have any previous medical or emergency services experience, if yes please elaborate? *

5. What are your expectations of membership at Larchmont Volunteer Ambulance Coprs? *

6. What are you interested in becoming? *

7. What is the time investment you are looking to make as a member of Larchmont Volunteer Ambulance Corps? *

8. Do you have any current of future plans that may limit your ability or time to volunteer, if yes please elaborate? *

Other Information

Are you a certified EMT? *

Do you have a valid drivers license? *

Any Known Members, if yes please list *

Have you applied previously? *

Have you previously applied to and been rejected from any other EMS agency including Larchmont VAC? *

Are you currently a volunteer member of any other VAC or EMS agency in New York State? If so, please list affiliation(s) in 'Any Additional Information' below. *

Any Additional Information *

By submitting this form I herby give permission to the Town of Mamaroneck/ Village of Larchmont Volunteer Ambulance Corps to verify information concerning my character and advise you thereof for the purpose of becoming a member of the Town of Mamaroneck/ Village of Larchmont Volunteer Ambulance Corps. A routine inquiry may be made into this application to provide us with information concerning your personal character. It is also noted that if I am under 18 years of age my parents or legal guardians approve of this application.

I understand that any false statements made hereon will automatically disqualify me from membership in the Town of Mamaroneck/ Village of Larchmont Volunteer Ambulance Corps.

Submit