Rockland County Volunteer Enrollment Form (Confidential)

Thank you for considering dedicating your free time to help your community in emergency situations. Please fill out and submit the following form and we will reach out to you as soon as possible.

Full Name: (required)

Date of Birth:

Male Female 




Zip Code

Your Email

Home Phone

Alternate phone:


Employment status:

Level of education:

How did you find out about volunteering?

Have you seen or were you influenced by our promotional marketing materials? (check all that apply)
 Road Sign Newspaper Ads/Articles Website TV/Radio Ads Posters Literature In-person Presentation None of the above

Your Reason for Volunteering: (check all that apply)
 Community Service Social Environment Member Benefits Skills Training

Previous experience: (click all that apply)
 Fire EMS Medical Military Law Enforcement None Other

You are interested in joining:

Do you have a specific area of interest?


Enter the above code (anti-spam):