Cary CERT Membership Information Form

First Name *

Last Name *

Nick Name

Address (Street, City, State, ZipCode) *

Email *

Home Phone *

Cell Phone *

Work Phone

Cary Fire District Number *

Occupation

Any Specialized Skills?

How did you learn of Cary CERT?

Have you completed the CERT Basic Course? If so, please provide a copy of the certificate for the completed course to by submitting it in person, or emailing it to carycert@gmail.com or mailing it to Cary CERT, PO Box 4765, Cary, NC 27519. *

Have you completed FEMA’s Introduction to Incident Command System, IS-100.B Course? If so, please provide a copy of the certificate for the completed course to by submitting it in person, or emailing it to carycert@gmail.com or mailing it to Cary CERT, PO Box 4765, Cary, NC 27519.

Have you completed FEMA’s ICS for Single Resources and Initial Action Incidents, IS-200-B Course? If so, please provide a copy of the certificate for the completed course to by submitting it in person, or emailing it to carycert@gmail.com or mailing it to Cary CERT, PO Box 4765, Cary, NC 27519.

Have you completed FEMA’s National Incident Management System IS-700.B Course? If so, please provide a copy of the certificate for the completed course to by submitting it in person, or emailing it to carycert@gmail.com or mailing it to Cary CERT, PO Box 4765, Cary, NC 27519.

Are you a member of the Cary CAP (Citizens Assisting Police) Team?

Are you a member of a Neighborhood Watch?

If so, what neighborhood?

Have you taken a First Aid course?

If completed, Date Taken:

Have you taken a CPR course?

If completed, Date Taken:

Are you an amateur radio operator?

If so, your License Class

If so, your Call Sign

Any functional limitations needing accommodations?

*