Name

Kenai Peninsula Borough
Community Emergency Response Team (CERT)

CERT Program Instructor Survey

Please help us make the most of your volunteer time and interest!

Name:

Mailing Address:

Physical Address:

Home Phone:

Work Phone: Cell Phone:

Email Address:

Best way to contact you: Home Phone Work Phone Cell Phone Email

Estimated number of hours you can commit each year:

Please list the year and location of any CERT classes, meetings, or activities you've participated in:

Have you taken the CERT Train The Trainer (TTT) Course? Yes No

If yes, when?

Would you be interested in a refresher training that focuses on teaching skills? Yes No

Place a check next to all areas that you wish to be considered for:

Lead Instructor

Co-Instructor for:

	Emergency Preparedness	Exercise Safety Officer
	Fire Safety/Hazardous Materials	Light Search & Rescue
	Emergency Medical Operations	Disaster Psychology

Please list any other skills that you would be willing to share with CERT volunteers (ex: GPS, orienteering, SAR, wilderness medicine, ham radio, etc.):

Additional comments or questions:

Thank you for your participation!