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Volunteer Application (CERT and BuCART)

  1. CERT-CART

  2. Team Selection*

    Indicate the team or teams for which you are applying for membership:

  3. Gender

  4. Employment Information

  5. Describe any employment history that you feel would be relevant to this application.

  6. Describe any educational history that you feel would be relevant to this application

  7. Describe any previous volunteer experience or involvement.

  8. FEMA Education

    Mark any FEMA / NIMS classes completed.

  9. If you completed the prerequisite 20-hour CERT Class through someone other than Butler County Emergency Mgmt, provide the dates and location of your CERT Class (you will also be asked to provide a copy of your completion certificate prior to finalizing your placement).

  10. Volunteer Skills

  11. Medical Certifications and Qualifications

    Mark any active medical certifications or qualifications that you currently possess (do not include lapsed or expired certifications).

  12. Firefighting or Rescue Certifications and Qualifications

    Mark any active firefighting or rescue certifications or qualifications that you currently possess (do not include lapsed or expired certifications).

  13. Law Enforcement Certifications and Qualifications

    Mark any active law enforcement certifications or qualifications that you possess (do not include lapsed or expired certifications).

  14. Other Certifications and Qualifications

    Mark any additional active certifications or qualifications that you possess.

  15. List any other qualifications that you feel would be relevant to this application. Feel free to elaborate on any of the items marked above, as well.

  16. Participation Options (CERT applicants only)

    The CERT team is broken into seven functional areas, giving participants a variety of ways to serve and be involved. Indicate the groups in which you are interested in participating.

  17. Other Information*

    Have you ever been convicted of and/or placed on probation for a criminal or traffic offense?

  18. Conditions and Digital Signature*

    Please note that by clicking "agree," you have signed this application, indicating that you understand, acknowledge and agree to the following conditions: 1. Butler County Emergency Mgmt is under no obligation to accept any applicants to its volunteer teams. 2. A background check may be conducted prior to placement into a volunteer position. 3. Any false statements or misrepresentation on this application will be cause for refusal of placement or immediate dismissal at any time during placement. 4. Volunteers affiliated with County departments are held to the same standards and policies as County employees, including standards and policies on public conduct, use of County equipment, use of controlled substances, harassment, etc. Applicants agree to abide by all volunteer program and County policies; failure to do so will be cause for dismissal from the program.

  19. Questions?

    If you have any questions related to the application, please contact Butler County Emergency Management at (316) 733-9796.

  20. Leave This Blank:

  21. This field is not part of the form submission.