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CERT Community Volunteer Application

All information will be treated confidentially. Please answer all question as completely as possible.
Name(Required)
Address(Required)
Emergency Contact(Required)
Group Address
Group Contact Name
What days are you available to volunteer?(Required)
What times are you available to volunteer?(Required)
Would you be available to assist in preparedness activities/projects?(Required)
Please reply with details on the numbers of times per week, month or year.
Licenses (Drivers & Professional)
MM slash DD slash YYYY
Please Check: I wish to become a trained CERT Member. Will require completing 24 hours of the FEMA CERT curriculum.
Please rate your skills in all of the areas that apply to you:
Please tell us about your licensure and/or experience in the following areas, if any:
I verify that the information I have given herein is current and accurate to the best of my knowledge. I also verify that I have not been convicted of a felony or, with the last 24 months, been convicted of a misdemeanor that resulted in imprisonment. If this information is in complete or untrue I understand that my volunteer assignment will be terminated.
MM slash DD slash YYYY
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© 2023 Quad City CERT | Quad City CERT is a 501(c)3 non-profit organization | Employer Identification Number: 26-2192213 | All donations can be considered a tax-exempt, charitable contribution.