Walnut Creek C.E.R.T. Registration (new patch)
The following contact information is critical to organize your Walnut Creek CERT area and respond to an emergency.

This information is strictly confidential and is only visible to other registered members of your specific CERT area (e.g., Buena Vista, Lar Rieu, Heather Farm, etc.).

Leave BLANK any fields that you do NOT want to share. If you change your mind and want to quit, just close this webpage (do not click Continue nor Submit).


Connectez-vous à Google pour enregistrer votre progression. En savoir plus
(1) CERT Group *
If you are a CERT graduate, please check the CERT Area to which you belong.  If you are a trained EOC Radio Operator, check "CERO (WC EOC Comms)". If you belong to a non-Walnut Creek CERT group, please click "Other:" and put the location of your CERT group. If you are NOT a CERT graduate, please click "Guest".
(2) First Name *
Please enter the name you would like CERT people to use to address you.  For example, if your given name is "Robert", but you want people to address you as "Bob", please enter "Bob."
(3) Last Name *
(4) CERT Group ICS role(s) *
Click one or MORE Incident Command Structure (ICS) areas in which you work or would like to work.  Note: For a role(s) not listed below, check " Other: " at the bottom of the list and enter a description.
Obligatoire
Your contact information
Please complete as much of the following contact information as you wish to share. Cell phone and home phone are most desired (useful during a drill, contact tree, or possibly a real event). Also, this information may be useful for nearby members to contact you in person if need be.
(5) Email *
This is your GMail address or non-Gmail address associated with a Google Account.  It is used to contact you with CERT related information, by other members, or to log into the database.
(6) Cell Phone *
xxx.xxx.xxxx       You should always carry your cell phone during a drill or emergency.  We might need it to verify that you are ok!  (Enter "none" if you don't have a cell phone)
(7) Cell Phone Provider *
Please select your cell phone provider.  This information may be used for automating an emergency contact tree by sending a text message to your cell phone number.  Note: For a provider not listed below, check " Other: " at the bottom of the list and enter the name of your provider.
(8) Home Phone *
xxx.xxx.xxxx We will use this number if we can't contact you with your cell phone. Maybe someone will know where you are.   (Enter "none" if you don't have a home 'phone)
(9) Street Address *
### <Street> <apartment unit, etc.>
(10) City *
(11) Zip Code *
Other information
Please complete as much of the following information as you wish to share.  This information may be useful to your CERT Area command post or CERT Area members.
(12) FRS/GMRS radios you own *
It is important that each CERT group has enough radios in an emergency.  Please indicate how many radios you own that are LEGAL FRS and/or GMRS.
(13) GMRS Call-sign
If you do NOT have an active FCC GMRS call-sign, please leave the space blank.  Otherwise, please enter your GMRS call-sign (this is NOT a HAM call-sign).
(14) Notes
Any special information you would like to include; special skills; equipment; etc.
Amateur (HAM) Radio Information
If you do NOT have an amateur radio license, check value "<none>" for item "(15) HAM Radios you own*" and then SKIP to the BOTTOM of this form and click the NEXT button.  

If you do have an FCC HAM license, please continue filling in the information...
(15) HAM Radios you own *
Check "<none>" if you do NOT own an amateur radio. Otherwise, uncheck "<none>", then check all boxes of HAM radios that you do own.
Obligatoire
(16) AT&T Yellow Box *
What is your experience level with the AT&T "yellow box" emergency radio located at the command post
(17) WC Registered HAM *
If you HAVE an amateur radio license and would like other WC CERT radio operators to see your information, click "YES". This info is important for emergencies, drills, and getting help. Only other registered WC HAMS can see your information (of course, members of your WC CERT Area can always see your registered information).  If you are a HAM, we strongly encourage you to answer "YES".   If you do NOT want to share your contact info with HAMS in other WC CERT areas, answer "NO".
(18) FCC HAM Call-sign
Enter your current FCC Amateur Radio call-sign if you have one.  Note: if you get a new call-sign, copy the old one to "Previous Call-signs" below, then put your new call-sign here.
(19) Previous Call-signs
Enter all the previous call-signs you've had (important for historical reports!)
(20) HAM License
If you have a Amateur Radio license, please select its license class below.  Otherwise, just leave "Choose" or select "none"
(21) HAM Cram VE Volunteer
If you are an accredited "Volunteer Examiner" and can help administer the WC CERT HAM Cram exam sessions, please select VE or VEC below.  Otherwise, just leave "Choose" or select "No".
Suivant
Effacer le formulaire
N'envoyez jamais de mots de passe via Google Forms.
Ce contenu n'est ni rédigé, ni cautionné par Google. Signaler un cas d'utilisation abusive - Conditions d'utilisation - Règles de confidentialité