Skip to content
Community Emergency Response Team (CERT) of Derry
1.
Please enter your name, cell phone number and email address Please note: all information will be kept confidential and standard text messaging rates may apply.
Name:
Phone Number (w/ area code):
Cellular Carrier (At&t, Verizon etc):
Email Address:
2.
Do you want to become an official member of the Community Emergency Response Team (CERT) of Derry?
Yes
No
Maybe
3.
In addition to your participation on the CERT, are you interested in learning more about also becoming a member of the Medical Reserve Corps. (MRC)? Please note: this team is organized through the Public Health, Emergency Preparedness Program at Parkland Medical Center.
Yes
No
4.
Please select the one team that you are most interested in being a part of:
Shelter Team (Staffing the emergency shelter, registering people, setting up cots etc.)
Emergency Management Team (Search and Rescue, building sandbags, door-to-door welfare checks, traffic control)
Communications Team (HAM radio operators)
Medical Reserve Corps. (MRC)
Please note: this team is organized through the Public Health, Emergency Preparedness Program at Parkland Medical Center.
5.
Are you interested in also being trained to be able to participate on any other team?
Yes
No
If yes, please specify which other team(s):
6.
Are you interested in becoming a team leader? (Shelter Team Leader, Emergency Management Team Leader etc.)
Yes
No
If you answered yes, which team?
7.
Have you ever or are you currently volunteering for a similar organization?
Yes
No
If you answered yes, please specify:
8.
What day(s) of the week work best for you to attend a meeting or training event? Choose all that apply.
Monday Night
Tuesday Night
Wednesday Night
Thursday Night
Friday Night
Saturday
Sunday
Saturday Night
Sunday Night
9.
Approximately, what size T-Shirt fits you best?
X-Small
Small
Medium
Large
X-Large
XX-Large
10.
Are there any specific areas of concern or specific scenarios that you feel would not be a good fit for you as a volunteer of CERT?
11.
Do you have any questions, concerns or suggestions about the CERT that have not yet been addressed?
