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Page 1 of 4 Last Revised: June 26, 2012 G:\Emergency Management Division\Volunteers\CERT\Templates\Forms\Registration Forms\Fire Volunteer Application.r2012.docx Anaheim Fire & Rescue Department CERT & RACES Volunteer Application Form (applicants must be at least 14 years of age) BASIC APPLICATION DATE BIRTH DATE NAME LAST FIRST M.I. ADDRESS NUMBER STREET APT. # ADDRESS LINE 2 CITY STATE ZIP PHONE NUMBER HOME WORK CELL CELLPHONE CARRIER Choose an item. E-MAIL HOME WORK CA Drivers License No. (if applicable) Professional License No. Amateur Radio License No. Radio License Level: Technician General Extra Emergency Contacts NAME LAST FIRST M.I. Relation NAME LAST FIRST M.I. Relation Volunteer Application Checklist (for office use only) BASIC REQUIREMENTS IS-100 IS-700 Fingerprints Background Check Disaster Service Worker Form CERT Level I CERT Class Certificate CERT Level II First Aid, CPR, AED Shelter Training CERT Level III (CMAP) IS-200 CMAP Responder RACES Radio License Equipment Issued CERT Vest RACES Vest Volunteer Polo CERT T-Shirt RACES T-Shirt Hard Hat Volunteer ID Card Select from Dropdown List Alltel ---PAGE BREAK--- Page 2 of 4 Last Revised: June 26, 2012 G:\Emergency Management Division\Volunteers\CERT\Templates\Forms\Registration Forms\Fire Volunteer Application.r2012.docx Skills, Specialties, Talents and Interests Please check all that apply: Expert Good Minimal Want to Learn LEADERSHIP Supervisory or management experience, office management, team leadership LOGISTICS Inventory management and control, purchasing, inventory record keeping MAINTENANCE / CUSTODIAL Construction, mechanical repair, auto repair, building inspector OFFICE / ADMINISTRATIVE Organizational skills, data entry or typing, filing, scheduling phone calls COMPUTER SKILLS Proficient with Microsoft Office software, proficient using websites and completing searches for information COMMUNICATIONS Writing skills, newsletters, webpage or blog writing, public speaking PHOTOGRAPHY / VIDEO Photography or video production, may be proficient or understand photo editing software such as Photoshop or video software such as iMovie, Final Cut Pro or Adobe Premiere EVENT PLANNING Coordination, registration systems, decorating, event logistics FOOD SERVICE Preparation and distribution of food and beverages, understanding of heath and sanitation requirements for food service Others/specify: Approximately how often do you prefer to volunteer for the program? Daily A few times a week Once a week Every other week Once a month Every other month A few times a year Which of the following online communities or social networks do you participate in and how often? Network Daily Weekly Network Daily Weekly Facebook A Blog LinkedIn Twitter Yelp Flickr YouTube Yahoo FourSquare Google + MySpace Are you currently subscribed to Anaheim Alert, the City’s text and email notification system? Subscription for Anaheim Alert is available at www.anaheimalert.net. Volunteers are placed in this system to be notified for activations. Yes No Are you currently subscribed to AlertOC; the City/County email, phone, cell phone and text alert notification system? Subscription for AlertOC is available at www.AlertOC.org. Volunteers are placed in this system to be notified of activations and events. Yes No ---PAGE BREAK--- Page 3 of 4 Last Revised: June 26, 2012 G:\Emergency Management Division\Volunteers\CERT\Templates\Forms\Registration Forms\Fire Volunteer Application.r2012.docx I am interested in joining the following CERT Specialty Teams: Team Description EOC Admin. Team Members of the EOC Admin. Team are assigned positions supporting Emergency Operations Center (EOC) activations and provide administrative support to the Office of Disaster Preparedness (ODP). Members are computer literate with experience in the Microsoft Office Suite and/or experience with EOC and ODP operations. Hotline Team Members of the Hotline Phone Team provide phone support during emergencies or situations in which there is a heavy call volume from the public. Additionally, members who are social media savvy will be asked to monitor social media messages on behalf of the PIO. They are responsible for answering incoming hotline calls and providing approved information to the general public. Members have great communication skills, patience, customer service, and map reading skills. Members may also be comfortable using Google Maps to demonstrate evacuation areas or assist with social media reports. Speakers’ Bureau The Speakers’ Bureau provides public speaking services, and represents the CERT and RACES programs at community forums. Ideally they are comfortable using Power Point, however, there are flip-chart systems as well. The speaker’s bureau members also participate in community events by assisting the department with setting up and hosting a booth or other community demonstration. Welcome Committee This committee follows up with the new and interested members to ensure their completion of the CERT training classes, ham radio licensing, fingerprinting and ICS classes are completed. They make regular contact with the prospective volunteer during the application period to keep them informed of their status and to invite and welcome them to membership meetings. Hallmark Team Hallmark Team members provide contact and outreach to ill or injured program volunteers. They help recognize birthdays, volunteer anniversary dates and milestones, and helping with recognition for participation in activities. They also serve as the official secretary of both volunteer programs and assist in distributing emails, messages and other information. Shelter Team The CERT Shelter Team will assist the Anaheim EOC Care and Shelter Branch as necessary for deployment and operation of local shelters. Shelter Team members are all shelter trained through the American Red Cross. American Red Cross Shelter Management training is also provided. Disabled, Access and Functional Needs Team (DAFN) The team is specially trained to recognize and handle disabilities and special needs residents during a disaster. Members have experience caring for people with disabilities or special needs and/or have taken specific training to understand disabilities and special needs. This team provides outreach to the disabled and special needs community, and develops partnerships with local residents to maintain accountability for the special needs population. Fire Support Team This team receives special training in providing rehab services (cooling, water, etc.) to firefighters during fire incidents. They will be scheduled for shifts of deployment and activated upon request of the Fire Captain or Battalion Chief at a fire scene. Additionally, the fire support team mayb e used during daily activities at the fire house such as answering phone calls, assisting with public school groups and tours. This team may also be activated to assit the department with Fire Watch Patrols in the canyon during Red Flag Warnings. Fundraising Committee The Fundraising Team specializes in procuring additional funding for the not for profit Anaheim Community Foundation/CERT program through fundraising. This includes reaching out to local businesses and organizations, as well as organizing fundraising events locally. CERT Leadership / Advisory Board This is a new committee that will develop a leadership structure for the CERT program and increase volunteer involvement at an administrative level. ---PAGE BREAK--- Page 4 of 4 Last Revised: June 26, 2012 G:\Emergency Management Division\Volunteers\CERT\Templates\Forms\Registration Forms\Fire Volunteer Application.r2012.docx Team Rally Points Team sites comprise members of CERT and RACES organized to form a Neighborhood Team. Please select the team closest to your residence from the established sites below. If you are interested in becoming a Team Captain and establishing a new CERT Neighborhood Team Site, please list the major cross streets for your residence, and talk to the CERT Program Manager for more information. CERT Neighborhood Team Sites Major Cross Streets Twila Reid Park Orange Ave. and Western Ave. Hampton Street Broadway and Magnolia Ave. West Anaheim Community Center Orange Ave. and Beach Blvd. Pearson Park Lincoln Ave. and Harbor Blvd. Stoddard Park Katella Ave. and 9th St. Magnolia Baptist Church Orange Ave. and Magnolia Ave. Albert Schweitzer Elementary School Broadway and Dale Ave. Magnolia School District Broadway and Magnolia Ave. Modjeska Park Ball Rd. and Nutwood St. Yorba Regional Park La Palma Ave. and Weir Canyon Rd. Temple Beth Emet Cerritos Ave. and Euclid St. Eucalyptus Park Santa Ana Canyon Rd. and Fairmont Blvd. Centralia School District La Palma Ave. and Valley View St. Ronald Reagan Park Weir Canyon and Serrano Ave. Start my own Team Site List Location: May we contact you via email with CERT information, such as newsletters and CERT updates? Yes No Our Policy It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age or disability. Thank you for completing this application form and for your interest in volunteering with us. Return application to: CERT & RACES / Emergency Management, 500 E. Broadway Ave, Anaheim, CA 92805