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2. 
3. Westland Community Emergency Response Team Volunteer Registration Form

   All information provided in this form is subject to Freedom of Information Act requests subject to State law.

5. Congratulations on taking the first step towards joining the City of Westland Community Emergency Response Team (CERT)!  The CERT program volunteers assist in times of need by supporting the City staff with basic emergency services.  In order to join please fill out the questions below in total so that the City can review your application to this important program.  

7. First Name
8. Last Name
10. Email Address
11. Phone Number
13. Street Address
15. Age
16. Have you ever been convicted of a felony?

    1. Yes
    2. No
18. Areas of volunteering with which you have an interest (check all that apply)

    1. Administrative Work
    2. Communications
    3. Disaster Relief

    1. First Aid or Skilled Medical
    2. Food Drives
    3. General Assistance

    1. Outreach Programs
    2. Safety Education
20. Please list any special skills or knowledge you would consider relevant to this program

22. I have answered all the above questions honestly and to the best of my ability.  I understand that before I am accepted into the Westland CERT program, I  must pass a background check as part of the application process.

24. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature
27. Date
    Date
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field