| Last Name: | First: | Middle: |
| Home Address: |
| City: | State: | Zip: |
| Business Address: |
| City: | State: | Zip: |
| Home Phone: | Business: | Fax: |
| E-mail Address: |
| Wilton Community Emergency Response Team (CERT) Volunteer Application |
| Please Print Clearly: | ||||||
|
||||||
| ||||||
|
||||||
| ||||||
|
||||||
| ||||||
|
||||||
| ||||||
|
||||||
| ||||||
|
||||||
| ||||||
|
||||||
| Experience: (include both paid and volunteer experience, beginning with most recent) | |||
| Organization Name: |
Address: |
Phone: |
|
| Dates: |
Supervisor's Name/Title: |
||
| Organization Name: |
Address: |
Phone: |
|
| Dates: |
Supervisor's Name/Title: |
||
| Organization Name: |
Address: |
Phone: |
|
| Dates: |
Supervisor's Name/Title: |
||
| Current License(s): | |||
| Type: |
Number: |
State: |
Expiration Date: |
| Type: |
Number: |
State: |
Expiration Date: |
| Education and Training: (begin with most recent) | |||
| Institution Name | City/State | Degree/Major | Date Attended |
| Volunteer Opportunities: (check activities which interest you or skills you possess) | |||
| ⌉ Blood Services ⌉ First Aid Stations ⌉ CPR/First Aid Education ⌉ HIV/AIDS Education ⌉ Disaster Education ⌉ Water Safety |
⌉ Disaster Services ⌉ Special Events ⌉ AFES ⌉ International Services ⌉ I.H.L. Training ⌉ Youth Programs |
⌉ Administrative ⌉ Casework ⌉ Finance ⌉ Communications ⌉ Word Processing ⌉ Development |
⌉ Leadership ⌉ Telerecruitment ⌉ Teaching ⌉ Fund Raising ⌉ Public Relations ⌉ Marketing |
| ⌉ Other __________________________________________________________________ | |||
| Avalability: (check all that apply) | |||
| Monday ⌉ Morning ⌉ Afternoon ⌉ Evening |
Tuesday ⌉ Morning ⌉ Afternoon ⌉ Evening |
Wednesday ⌉ Morning ⌉ Afternoon ⌉ Evening |
Thursday ⌉ Morning ⌉ Afternoon ⌉ Evening |
| Friday ⌉ Morning ⌉ Afternoon ⌉ Evening |
Saturday ⌉ Morning ⌉ Afternoon ⌉ Evening |
Sunday ⌉ Morning ⌉ Afternoon ⌉ Evening |
|
| Emergency Contact Information: | ||||||||
|
| Previous Red Cross Experience: |
| Have you ever worked as a Red Cross employee? If yes, give position, dates and location |
| Have you ever worked as a Red Cross volunteer? |
| Have you ever held any Red Cross certification (eg. Health & Safety instructor, DSHR member)? If yes, please list. |
| Please answer the following questions A "yes" answer to italicized questions will not necessarily disqualify any applicant. |
| Are you licensed to operate a motor vehicle in this state? |
| Has your license to operate a motor vehicle ever been revoked? If yes, please explain. |
| Have you ever been bonded? |
| Has your bonding ever been revoked? If yes, please explain. |
| Have you ever been convicted of a felony, or withing the past 24 months, of a misdemeanor that resulted in imprisonment? If yes, please explain. |
| Have any of your Red Cross certification ever been revoked? If yes, please explain. |
| VOLUNTEER CONSENT FOR REFERENCE AND BACKGROUND CHECKS
I do hereby give the Town of Wilton permission to inquire into my educational background, references, driving record, police records, employment, and/or volunteer history. I further give permission to the holder of any such records to release the same to Wilton CERT. I do hereby hold the Town of Wilton and Wilton CERT harmless from any liability, whether civil or criminal that may arise as a result of the release of this information about me. I further hold harmless any individual, agency, business, or corporation that provides information or documents to the Town of Wilton. I understand that the Town of Wilton will use this information as part of its verification of my volunteer application and periodically for evaluation purposes.
|
||||||||||