West Hartford CERT Interest Form

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Thank you for taking a few minutes to tell us about yourself and your interest in the West Hartford CERT. You can learn more about West Hartford CERT and training by visiting our website: https://www.westhartfordct.gov/town-departments/fire-department/emergency-management/community-emergency-response-team-cert

Please note, participants will be required sign an acknowledgement and waiver before participating in the training. You can review the waiver on our webpage

First Name *

Last Name *

Preferred name (if different from first name)

Pronouns

They/their, she/her, he/him, etc.

Best Phone Number

Is this a cellular phone or a landline? *

This is a cell phone

This is a landline

Other:

Can we text you at this number? *

Yes

Other:

What is the zip code of your current residence? *

Are you currently 18 years old or over? *

At this time, West Hartford CERT requires that participants be at least 18 years old at the time of their training.

Yes, I am over the age of 18

Yes, I am 18 years old

No, I am not yet 18 years old

Are you a resident of West Hartford? *

Residency is not required for CERT, but is preferred.

Yes

Other:

Do you work or study in West Hartford? *

Working and/or studying locally is not required for CERT.

Yes, I work in West Hartford.

Yes, I study in West Hartford.

Yes, I work AND study in West Hartford.

Other:

How did you learn about West Hartford CERT? *

Please share any prior experience you have, professional or civilian with emergency operations and/or disaster preparedness.

CERT does not require any prior experience, but we'd love to hear if you have any relevant experience. This may include: CPR training; previous CERT participation; professional experience in medicine, fire, police, EMT, or other emergency services/response.

Please let us know if you are affiliated with any West Hartford businesses, associations, or educational institutions.

This may also include local clubs, alliances, committees, boards, organizations, etc. As we work to bring emergency prevention and preparedness to all community members, it helps us to know the other great ways our team members are engaging locally.

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