Membership Application

Complete this form to express interest in joining CERT Kingman. A team coordinator will follow up by email within a few days. No prior emergency-response experience is required.

Membership Application

Personal Information

Full name *

Email address *

Phone number *

Home address (city and zip)

Best days for meetings / training

Why do you want to join CERT? (optional)

Emergency Contact Information

Emergency contact name *

Relationship to you

Emergency contact phone *

Health & Well Being

Medical conditions or physical limitations we should be aware of (optional)

Specialized Training & Credentials

Current CPR / First Aid certification status

Relevant background (optional)

Professional licenses or certifications (optional)

e.g., EMT, RN, firefighter, HAM radio, FEMA ICS courses

HAM radio callsign (optional)

Do you have a valid driver's license?

Special skills or experiences relevant to volunteering (optional)

Language Skills

American Sign Language (ASL)

Languages spoken in addition to English (optional)

Proficiency in non-English language(s)

Signature

By typing your full name and date below, you certify that the information provided in this application is accurate and complete to the best of your knowledge.

Signature (type your full name) *

Date *