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General Contact Information

Are you currently employed?*
1. Yes
2. No
Does your employment involve responding to public health emergencies?*
1. Yes
2. No
Employer Name*
Employer Contact Number*
Do you hold any current licenses or certifications?*
1. Yes
2. No
If yes, please list with corresponding # or upload below (Please put N/A if you have none)*
License/Certifications Upload
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Do you have any physical limitations that would need to be considered when given assignments? (Please explain)*
Primary Language*
Other languages that you speak fluently*
Do you know American Sign Language?*
1. Yes
2. No
Do you hold a valid driver's license?*
1. Yes
2. No
Are you current or former military personnel?*
1. Yes
2. No
Are you currently a member of another C.E.R.T. or Medical Reserve Corps?*
1. Yes
2. No
If yes, please list (with City)
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For some emergencies, there may be cases where staff is needed for 24 hours a day (shifts normally last from 8-12 hours).
Please check ALL of the shifts that you are willing to work:*
1. 8 a.m. - 4 p.m.
2. 4 p.m. - Midnight
3. Midnight - 8 a.m.
Will you be able to attend all class sessions when they become available?*
1. Yes
2. No
Please select which volunteer program you are interested in:*
1. C.E.R.T. only
2. Medical Reserve Corp only
3. Both

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