Wilton Community Emergency Response Team (CERT)
Volunteer Application
Please Print Clearly:
Last Name:     First:     Middle:   
Home Address:  
City:     State:     Zip:   
Business Address:  
City:     State:     Zip:   
Home Phone:     Business:     Fax:   
E-mail Address:  

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:
Name:     Relationship:     Address:     Phone:   

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Has your license to operate a motor vehicle ever been revoked?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.


Name Social Security Number
Signature Date
Witness Date