You can always press Enter⏎ to continue
Clay County CERT - Volunteer Registration
Clay County CERT - Service & Management Division
START
Accessibility
Enabled Form
1
Status
Please Select
Pending
Pending
Please Select
Pending
Previous
Next
Submit
Submit
Press
Enter
2
Date of Application
*
This field is required.
/
Date
Month
Day
Year
Previous
Next
Submit
Submit
Press
Enter
3
Preferred Position
*
This field is required.
CERT Member (w/ Training)
Education & Outreach
Blood Drive Team
Administrative/Executive
Service & Managment
Teen & Youth
Logistics & Operations
Other
Previous
Next
Submit
Submit
Press
Enter
4
Legal Name
*
This field is required.
First Name
Middle Name
Last Name
Previous
Next
Submit
Submit
Press
Enter
5
Date of Birth
*
This field is required.
/
Date
Month
Day
Year
Previous
Next
Submit
Submit
Press
Enter
6
Driver License Information
Driver Licence Number
State on License
Previous
Next
Submit
Submit
Press
Enter
7
Contact Information
Primary Phone Number
Secondary Phone Number
Mailing Address
Previous
Next
Submit
Submit
Press
Enter
8
Email Address
*
This field is required.
example@example.com
Previous
Next
Submit
Submit
Press
Enter
9
Volunteer Demographics
(Optional)
Please Select
12-17
18-30
31-40
41-50
51-60
61-70
71-80
81-90
91+
Please Select
Please Select
12-17
18-30
31-40
41-50
51-60
61-70
71-80
81-90
91+
Age Range
Please Select
Woman
Man
Transgender
None of these
Decline to Answer
Please Select
Please Select
Woman
Man
Transgender
None of these
Decline to Answer
Gender
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Race & Ethnicity
Please Select
Primary
Secondary or GED
Trade
College
Graduate
Please Select
Please Select
Primary
Secondary or GED
Trade
College
Graduate
Highest Level of Education
Please Select
Search Engine - Google
Twitter
Instagram
Youtube
Facebook
A post from a friend on social media
Radio
TV
Print
Word of mouth
Please Select
Please Select
Search Engine - Google
Twitter
Instagram
Youtube
Facebook
A post from a friend on social media
Radio
TV
Print
Word of mouth
How did you hear about us?
Please Select
Employed
Unemployed
Disabled
Other
Decline to Answer
Please Select
Please Select
Employed
Unemployed
Disabled
Other
Decline to Answer
Employment Status
Preferred Pronouns
Preferred Name
Previous
Next
Submit
Submit
Press
Enter
10
Emergency Contact
Emergency Contact Name
Emergency Contact Age
Relationship to Applicant
Primary Phone Number
Secondary Phone Number
Physical Address
Previous
Next
Submit
Submit
Press
Enter
11
Personal Statement
Previous
Next
Submit
Submit
Press
Enter
12
Personal Photo
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Submit
Press
Enter
13
Volunteer Applicant Agreement
*
This field is required.
I have read and understand the content of this application and below linked document and accept that it applies fully upon accepting this agreement! By selecting the "I Accept" button and signing in the space below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. Please sign your full legal name in the box below and select "(I Agree)" to Digitally Sign this document! You are agreeing to all policy including this electronic signature policy by submitting and accepting this application agreement! If for any reason it is deemed necessary this electronic signature can be revoked, where other means for agreement will be discussed with the applicant on an individual basis.
Previous
Next
Submit
Submit
Press
Enter
14
Applicant Agreement Signature
*
This field is required.
Previous
Next
Submit
Submit
Press
Enter
15
Legal Guardian(s) Consent
Do you consent to the above mentioned individual(s) participation, acceptance of the terms set forth in the Volunteer Applicant Agreement(s), agree that the information contained within this form is correct, that you are a Legal Guardian of the above mentioned individual, and that your age is (>18)?
YES
NO
Previous
Next
Submit
Submit
Press
Enter
16
Legal Guardian(s) Signature
MUST BE COMPLETED BY LEGAL GUARDIAN (Age >18)
Previous
Next
Submit
Submit
Press
Enter
17
MyVID
Previous
Next
Submit
Submit
Press
Enter
18
Skill(s) & Training(s)
CPR
First Aid
Other
Previous
Next
Submit
Submit
Press
Enter
Should be Empty:
Clay County CERT - Volunteer Registration
[Edit]
Question Label
1
of
18
See All
Go Back
Submit
Submit
.627d1d00474d93.74372702.png)