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Online Registration

CLASS REGISTRATION
AND
MEMBERSHIP APPLICATION

Thank you for your interest in taking the Kaufman County CERT Training Classes and becoming a member of Kaufman County CERT, Inc.

When you click the start button below, you will start the process of registering for our training sessions and for membership into the organization. This is an interactive form, designed to collect the same information that is collect by our off-line applicaitons. Once you have completed this form, your information will be transmitted to us and we will use this information to complete an off-line form that you will sign upon arrival at your first training session.

All information collected through this form is protect under the volunteer privacy policy of Southern Search & Rescue, Inc., our parent organization.

The information provided by this application will allow us to place you in the next training session that meets the requirements that you have requested and allows us to provide other options if needed. Please be sure to use an email address that you check on a regular basis and that emails from kccert.org will be received.

Please click the start button below to start the application.

Download and print out registration form and application.

Training Registration Form 2007

This portion of our application form is to "pre"-register for our classes and membership into the Kaufman County CERT program. Training class is limited and only those that have completed the APPROVED registration forms will be allowed in.

I would like to register for the eight-session CERT training and would like to attend on:

Saturday Evening Class

Sunday Evening Class

2 Day Accelerated Class

3 Day Business Class

Please Print Clearly

Name:

(First and Last)

Street Address:

Address Cont.:

City:

State:

Zip Code:

Nearest Cross Street To Your Home:

Telephone (Day):

Please Use 999-999-9999 Format

Telephone (Evening):

Please Use 999-999-9999 Format

Email At Which You Want To Receive CERT Information:

*Please mail this form (one registration per form, please) to:

Kaufman County CERT
1904 Melody Circle
Kaufman, TX 75142-9684

For more information about the Kaufman County CERT program, please check http://www.kccert.org or call (972) 704-4318.

Once you have submitted this registration form, you will go to the actually application. After completing the application, you will receive an email with information and will be informed of your registration status, usually with 48 hours. Please understand that you will be required to sign you application at your first meeting.

* Do Not Mail A Copy Of This Online Form. Only Mail If You Use The PDF Form

If you wish to complete the PDF Application, click here

Information sent using this form will be imported into the official charity application form. This page has been designed to look very similar to the true form.

First Name:

Middle Initial:

Last Name:

Social Security #:

Age:

Email Address:

Address:

Apt #/Other:

City:

State:

Zip Code:

Home Phone:

Listed

Unlisted

Work Phone:

Ext.:

Alternate Phone/Pager:

Voice

Digital

Date of Birth:

Sex:

Male

Female

Martial Status:

Yes

Children:

Yes

If Yes, Number Of Children:

Spouse's Name (if any):

Children(s) Name:

PERSONAL: (Items marked in bold red are required. Failure to include this information will result in a rejection of this application)

Please use 123-12-1234 format

Drivers License and Vehicle Insurance Information: The State of Texas requires that all motorist have a valid driver's license and proof of insurance. As many of our official activities require driving your personal vehicle or may require you to drive a team owned vehicle, it is necessary for us to ask for this information. Failure to supply this information WILL NOT affect your application for membership.

Drivers License #:

State of Issue:

Expires:

Insurance Agent/Company:

Phone:

Policy Type:

Comprehensive

Liability Only

Vehicle 1:

Make:

Model:

Year:

Color:

4x4:

Yes

Vehicle 2:

Make:

Model:

Year:

Color:

4x4:

Yes

Employment Information: It is the policy of Kaufman County CERT NOT TO RELEASE work locations or phone numbers without prior permission of the member involved. However, it is of benefit to KCCERT to be aware of where our members are employed, at avoid cases of conflict of interest or accidentally jeopardizing a members job. Failure to supply this information will not affect you application for membership.

Place of Employment:

Position:

Type of Business:

Address:

City:

State:

Zip Code:

Emergency Contact Information:

Name:

Phone #:

Relationship:

Alternate Phone #:

Physician Name:

Number:

Other Organizations Involved With: Due to the multitude of other agencies or organizations that KCCERT works closely with, it is important for us to know what other organizations, clubs, etc. that you may currently belong to. This information will enable us to determine the amount of time that you may be able to contribute as a member of SSAR in time of emergency. For example, belonging to a Volunteer Fire Department may cause a conflict if KCCERT is called out at the same time to help with the fire or other disaster. No member is expected to be 100% available. There will be times when your family, church, employment or other obligations may take priority over KCCERT Team meetings and activities.

Name:

Purpose:

Position:

Name:

Purpose:

Position:

Name:

Purpose:

Position:

Personal References: KCCERT membership carries a heavy responsibility. Our members must be able to work closely with law enforcement officers and the general public in a position of trust and responsibility. This is the reason for requiring three (3) non-family character references. Failure to supply this information WILL result in a rejection of the application.

Name:

Address or Phone #:

Relation:

Name:

Address or Phone #:

Relation:

Name:

Address or Phone #:

Relation:

Reason(s) for wanting to become a member or help: Briefly state why you wish to become a KCCERT member. Failure to supply this information WILL result in a rejection of this application.

Personal Skills / Training / Hobbies: KCCERT members come from a wide variety of backgrounds and experiences. It is extremely helpful to the KCCERT Board of Directors to be aware of any special skills, training or hobbies that maybe use to the team. This includes such things as medical training, disaster training, special drivers licenses, SCUBA and others. The list is endless. Failure to supply this information WILL NOT affect your application.

Shirt Size: Many of our events which we work, often provide items such as T-Shirts to the volunteers who work the event. While we prefer that our members wear their uniform shirts rather than these T-Shirts during the event, we still need to know you preferred T-Shirt size to aid in telling the event sponsors how many of which sizes we need them to provided. Please indicate below, your preferred T-Shirt size. ( It doesn't have to be your actual size and you may change it later it you wish ).

Small

Medium

Large

X-Large

XX-Large

Other

List of impairments, limitations, phobias, etc.: We ask that you provided this information so that we can work with you in your position as a member. Someone who is closterphobiac, we would not ask to go into a small cave or tunnel. This information is to help us help you, but is not required.

Criminal Record: Due to the nature of our services, and the possibility of involvement with children, we require this information. We CANNOT accept members that have been convicted of a felony. Additionally, any conviction of a crime related to kidnapping, abduction, assault, indecency with a child/cadaver, rape, molestation or registered as a child sex or adult sex offender will disqualify this application for membership. All other criminal charges will be looked at on a case by case basis, but, failure to supply this information WILL result in a rejection of this application.

Enter Code Number:

Todays Date:

Desired Username:

Password:

Must be at least 6 letters or numbers

Signature:

I have read and agree to the

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Copyright © 2004 - 2009 Kaufman County CERT, Inc.
A Registered 501(c)3 Texas Non-Profit Corporation
We Are Not Affiliated Or Associated With Any Kaufman County Governmental Agency, Entity or Department.
We are a private non-profit corporation.
All Donations Are 100% Tax Deductible
A Division of Southern Search & Rescue, Inc.
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