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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.
*
Yes
No
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.
Yes
No
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.
Yes
No
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.
Yes
No
Are you a member of the Cary CAP (Citizens Assisting Police) Team?
Yes
No
Are you a member of a Neighborhood Watch?
Yes
No
If so, what neighborhood?
Have you taken a First Aid course?
Yes
No
If completed, Date Taken:
Have you taken a CPR course?
Yes
No
If completed, Date Taken:
Are you an amateur radio operator?
Yes
No
If so, your License Class
If so, your Call Sign
Any functional limitations needing accommodations?
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