CITRUS COUNTY
CERT
VOLUNTEER QUESTIONNAIRE
PLEASE PRINT CLEARLY
Name:_________________________________________________________________
First
Middle
Last
Mailing
______________________________________________________________________
Physical
Address:_______________________________________________________________
______________________________________________________________________
Home
Phone:_________________Business:_______________Cell:_______________
Email:_________________________________________________________________
Date
of CERT Training:__________________
Date of Birth:______________________
Current/Previous
Occupation:_____________________________________________
Special
Talents: ________________________________________________________
______________________________________________________________________
Languages other than English:____________________________________________
In Case of Emergency: Name of Person to Contact:___________________________
Emergency
Contact Phone:________________________________________________
Emergency Contact Person's Address:______________________________________
Even
though I cannot attend the organization meetings, I would like to participate in
the CERT
Activities:
Yes _____ No
_____
Available for:
Weekday________ or Weekend_________ Training
Classes?
A.M._______
or P.M._______ or
Both _______
Signature:_______________________________________________________________