Community Emergency Response Team (CERT) of Derry Question Title * 1. Please enter your name, cell phone number and email address Please note: all information will be kept confidential and standard text messaging rates may apply. Name: Phone Number (w/ area code): Cellular Carrier (At&t, Verizon etc): Email Address: Question Title * 2. Do you want to become an official member of the Community Emergency Response Team (CERT) of Derry? Yes No Maybe Question Title * 3. In addition to your participation on the CERT, are you interested in learning more about also becoming a member of the Medical Reserve Corps. (MRC)? Please note: this team is organized through the Public Health, Emergency Preparedness Program at Parkland Medical Center. Yes No Question Title * 4. Please select the one team that you are most interested in being a part of: Shelter Team (Staffing the emergency shelter, registering people, setting up cots etc.) Emergency Management Team (Search and Rescue, building sandbags, door-to-door welfare checks, traffic control) Communications Team (HAM radio operators) Medical Reserve Corps. (MRC) Please note: this team is organized through the Public Health, Emergency Preparedness Program at Parkland Medical Center. Question Title * 5. Are you interested in also being trained to be able to participate on any other team? Yes No If yes, please specify which other team(s): Question Title * 6. Are you interested in becoming a team leader? (Shelter Team Leader, Emergency Management Team Leader etc.) Yes No If you answered yes, which team? Question Title * 7. Have you ever or are you currently volunteering for a similar organization? Yes No If you answered yes, please specify: Question Title * 8. What day(s) of the week work best for you to attend a meeting or training event? Choose all that apply. Monday Night Tuesday Night Wednesday Night Thursday Night Friday Night Saturday Sunday Saturday Night Sunday Night Question Title * 9. Approximately, what size T-Shirt fits you best? X-Small Small Medium Large X-Large XX-Large Question Title * 10. Are there any specific areas of concern or specific scenarios that you feel would not be a good fit for you as a volunteer of CERT? Question Title * 11. Do you have any questions, concerns or suggestions about the CERT that have not yet been addressed? Done