Clay County CERT - Volunteer Registration

Status

Date of Application* This field is required.

Date

Preferred Position* This field is required.

CERT Member (w/ Training)

Education & Outreach

Blood Drive Team

Administrative/Executive

Service & Managment

Teen & Youth

Logistics & Operations

Other

Legal Name* This field is required.

First Name

Middle Name

Last Name

Date of Birth* This field is required.

Date

Driver License Information

Driver Licence Number

State on License

Contact Information

Primary Phone Number

Secondary Phone Number

Mailing Address

Email Address* This field is required.

example@example.com

Volunteer Demographics(Optional)

Age Range

Gender

Race & Ethnicity

Highest Level of Education

How did you hear about us?

Employment Status

Preferred Pronouns

Preferred Name

Emergency Contact

Emergency Contact Name

Emergency Contact Age

Relationship to Applicant

Primary Phone Number

Secondary Phone Number

Physical Address

Personal Statement

Personal Photo* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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.

Applicant Agreement Signature* This field is required.

Legal Guardian(s) ConsentDo 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)?

YESNO

Legal Guardian(s) SignatureMUST BE COMPLETED BY LEGAL GUARDIAN (Age >18)

Skill(s) & Training(s)

CPR

First Aid

Other