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Member Application

General Information

Preferred Contact: Home PhoneWork PhoneCell PhoneE-mail

Statistical Information

Date of Birth: Gender:

Emergency Contact Information

General Questions

Do you have any other skills or licenses that may be helpful to CERT? If yes please explain below. Examples: MD, RN, LPN, EMT, Prior CERT training, Amateur Radio, languages other than English, any others at all you believe would be helpful:

Do you have any personal health or civil issues that would impact your ability to volunteer? If so, please list here or speak personally with the CERT coordinator.

I fully understand that the CERT program is under no obligation to accept all interested volunteers. I hereby certify that all information on this application is accurate and correct and I hereby make application for membership in the City of North Port Community Emergency Response Team program. I understand that I am applying for a volunteer position without compensation and this is not an application for, nor a contract of, employment.

I understand that this application does not automatically make me a member and that further interviews and training may take place. I understand that membership in the program requires a commitment to keep training credentials current, to attend membership meetings whenever possible, and to volunteer to participate in functions or missions as often as I can. I understand that every attempt will be made to reduce the risks to volunteers; however, some risks may be present during an emergency, disaster, during training and at non-emergency events.

By checking this box I certify that I have read and understand this application: