Community Emergency Response Team (CERT) Application
Last
Name:
___________________ First Name:___________________ MI: _____
Address:
__________________________
City/Zip: ________________________
Home
Phone: (____) _________________
Work
Phone: (____)
_______________
Cellular
Phone: (____)________________ Pager Number: (____)______________
E-Mail:
___________________________ Alternate Contact: __________________
Sex: Male Female
Drivers License: Yes No
Date of Birth: _______________
Do
you have any physical or medical conditions that might affect your
participation in some of the practical exercises used in this course? Please explain: _________________________
________________________________________________________________________________________________________________________________
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name:
__________________________ Phone#: _________________________
Address:
________________________ City/Zip: __________________________
Do
you have any disaster-related training or experience? Yes
No
If yes,
please describe:
________________________________________________________________
________________________________________________________________
Do not answer any question that you
are not comfortable completing
References,
not related who have known you for at least one (1) year:
(1)
Name: _________________________ Phone#: ________________________
Address:
_________________________ City/Zip: _________________________
(2)
Name: _________________________ Phone#: ________________________
Address:
_________________________ City/Zip: _________________________
Preparing the Community
Areas
that I am willing to assist with
Sandbagging
Cleanup
Office help/Phones
Translator (list Languages): ________________________________________
Provide Transportation (4wheel drive)
Other/Special Skills
Non-emergency Projects (staff display booth, distribute
information, demonstrations/drills)
I have the following certifications (please attach a
copy)
EMT-B, EMT-I, EMT-P
RN or LPN
MD or DO
CDL
Electrician
Plumber
Heavy
Equipment Operator
Engineer
(type): ________________________________________________
Faith Based
Counselor: ___________________________________________
Amateur
Radio Operator
Other: ______________________________________________________
Minor Consent to Train
I am Aware that my son/daughter ____________________________ is enrolled in the
Date:
(Signature of Parent/Guardian)
Informed Consent, Waiver and Release
Agreement
Must also be filled out and returned