Youth Corps.
P. O Box 173
Peekskill, Ny 10566
Social Phone: (914) 737-5310
APPLICATION FOR MEMBERSHIP
Associate Member____ Active Membership____
Name:_________________________________________________________
Address:________________________________________________________
Telephone: (__)_______________ Date of Birth:___________
Notify in case of emergency:_______________________________________
Emergency Telephone # ___________________________________________
By whom were you referred to the corps_______________________________
Employer or School name;__________________________________________
Address:_________________________________________________________
Telephone #:__________________ How long there?:___________
List of physical limitations:__________________________________________
Have you ever been a member of any PCVAC or other agency?
(Fire/Ambulance)? Yes_____ No_____
Have you ever been convicted of a crime other than traffic infarction
Yes______ No_____