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* 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.

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* 2. Do you want to become an official member of the Community Emergency Response Team (CERT) of Derry?

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* 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.

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* 4. Please select the one team that you are most interested in being a part of:

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* 5. Are you interested in also being trained to be able to participate on any other team?

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* 6. Are you interested in becoming a team leader? (Shelter Team Leader, Emergency Management Team Leader etc.)

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* 7. Have you ever or are you currently volunteering for a similar organization? 

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* 8. What day(s) of the week work best for you to attend a meeting or training event? Choose all that apply.

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* 9. Approximately, what size T-Shirt fits you best?

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* 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?

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* 11. Do you have any questions, concerns or suggestions about the CERT that have not yet been addressed?

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