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Home
About Us
CERT Member Training
- Initial Training
- Continuing Training
Community Preparedness Classes
Join CERT
Questions?
- About CERT In General
- About Public Classes
Sponsors

Community Emergency Response Team of The Villages

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CERT Application For Membership

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- Step 1 of 4

All applicants are subject to a background investigation. Please provide all requested information. Only one person per application. Aug 2024

CONTACT INFORMATION

Name *

First Initial Last

Street Address *

Zip *

Village of Residence *

Email *

Email

Confirm Email

Telephone *

Seasonal Resident? *

Yes
No

What months are you typically away from the villages? *

PERSONAL INFORMATION

Birth Date *

Driver License Number *

Have you ever been convicted of a crime other than a traffic violation? *

Yes
No

Please explain below: *

Do you have any physical conditions / limitations you would like to share? *

Yes
No

Please explain below:

CERT assignments will be based on your ability to perform them

Have you ever been a member of another CERT team? *

Yes
No

Please provide more information

Where, when, special training or events, positions held, etc..

Special Skills or Qualifications

Emergency Management
Fire Service
Medical (EMT, Paramedic ,etc.)
Medical (Nurse, Physician, etc.)
Training
CPR Instructor
Marketing / Fundraising
IT
Finance / Administration
Logistics
Languages (including ASL)
Other

Tell us about any relevant past work or volunteer experiences. No special skills are required - we just want to best use the skills you have.

Please explain each checked above *

EMERGENCY CONTACT INFORMATION

Emergency contact name *

First Last

City *

State *

Email *

Email

Confirm Email

Telephone *

SURVEY AND SIGNATURE

What information source prompted your interest in joining CERT? *

Newspaper coverage
HOA/POA table
CERT First Aid booth
Mail center table
Club presentation
Personal contact by friend
Other - explain below

Other Source *

Agreement and Signature^*

I understand I will be required to attend training, team meetings and perform first aid patrols at events within The Villages totaling 40 or more hours every year.

label - participation yes no *

Yes
No

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

label - agree checkbox *

I agree

Todays date *

Digital signature *

Typing your name in this field and clicking on the Submit Application button constitutes an electronic signature of this form.

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The Villages CERT Foundation Inc is a fully qualified charity under section 501(c)(3) of the Internal Revenue Code

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Please support our sponsors / patrons who have donated:

Microsoft 365

SharePoint and Microsoft 365 for all members

Ready Alert

Notification and dispatching software

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Team Improver

Organizational chart software for SharePoint

Information Request

(CPR / AED)

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