CERT Member/POC Information Form
** The information on this form will only be shared with the Team Leadership **
Name
*
First Name Last Name
Address
*
Cell #
*
We need your Cell # so the Team can contact you when we need your assistance.
Email
*
example@example.com
Residency
*
Please Select
Full Time
Seasonal
CERT would highly prefer that all POCs be Full Time residents since hurricane season is when we have the greatest need for POCs in our com
Months Here (If Seasonal)
Oct - Mar, July etc
How would you like to participate on the Team?
*
Hurricane Point of Contact (NO Training Required)
CERT Volunteer (Training Preferred)
Would you like to attend CERT Training?
*
Yes
No
Would you attend bi-monthly CERT meetings?
*
Yes
No
Do you have any of the following: (Check all that apply)
Golf Cart
4 Wheel Drive Vehicle
Chain Saw
Pry Bar
Come-a-long
Chains and/or rope
Two-way Radio
Ham Radio
Generator
Helpful tools you can provide
Special skills/previous training: (Check all that apply)
Medical
First Aid
CPR
Police
Rescue
Fire Fighter
EMT
Nurse
Military
Other Skill/Training
Things willing to participate in: (Check all that apply)
Canvas Neighborhood
Work Phone/Two-way Radio
Transport
Staff an Emergency Center
Hand-out/Collect door-to-door
Document Activities
Help Form Hurricane Teams
Help Manage Hurricane Team
Rescue Team
Communication
Drill Preparation
Other
What Zone are you in?
Please Select
Zone 1
Zone 2
Zone 3
Zone 5
Zone 6
Zone 7
After hitting "Submit" a CERT member will contact you by email.
Submit
Should be Empty: