Navarre CERT Application

If you are interested in joining Navarre CERT, please complete the information below and submit the form.  Be sure you have read our Standards of Conduct page before applying for membership.  If you only wish to apply for CERT training, click here.

Note that items marked with an asterisk (*) and in BOLD are required entries.

*Name *Address
*City:     *State:     *Zip Code:
Home Phone Work Phone Cell Phone
Preferred contact number:  Home     Work     Cell
Gender:  Male Female Age Group:  Under 18 18-24 25-50 50-65 over 65

*E-mail address Occupation/Profession
Have you had any type of first responder training in the past? Yes No
      If Yes, what type and when?

Military Experience?  Civilian On Active Duty Retired       Specialty
Medical Experience?  Doctor Nurse Veterinarian PA     Other:

Background / Skills / Interests:

Amateur Radio -- Call sign:     Class:  Technician General Amateur Extra
Computers - What area(s)?
Graphic Art Public Speaking Teaching
Construction Administrative Fiscal
Logistics/Resource Planning Comm Planning/Amateur Radio Media
Contingency Planning Disaster Preparedness Disaster Response
Disaster Recovery Disaster Mitigation First Aid
CPR Certified Fire Safety Water Safety
Crime Prevention/Law Enforcement Traffic Safety Search and Rescue
Chain Saw Operation Bobcat/Backhoe Operation Hazmat

Languages spoken (other than English):

Once trained, would you be interested in facilitating training classes? Yes No

When could you begin volunteering?

Do you have any questions or comments?