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2. 
3. Team Selection*

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

   1. Community Emergency Response Team (CERT)
   2. Butler County Animal Response Team (BuCART)
5. First Name*
6. Last Name*
7. Middle Initial
9. Driver's License Number*
10. Driver's License State*
11. Driver's License Expiration*
12. Date of Birth*
14. Address 1
15. Address 2
17. City
18. State
19. Zip Code
21. Primary Phone Number*
22. Secondary Phone Number
23. Email Address
25. Emergency Contact 1 Name
26. Emergency Contact 1 Phone
28. Emergency Contact 2 Name
29. Emergency Contact 2 Phone
31. Employment Information

    1. Employed full-time
    2. Employed part-time
    3. Not currently employed
    4. Retired
    5. Student
32. Employer Name and City
33. Job Title
35. Other Employment History
    Describe any employment history that you feel would be relevant to this application.
36. Education History
    Describe any educational history that you feel would be relevant to this application
38. Volunteer History
    Describe any previous volunteer experience or involvement.
39. FEMA Education

    Mark any FEMA / NIMS classes completed.

    1. ICS 100
    2. ICS 200 or 2200
    3. ICS 300 or 2300
    4. ICS 400
    5. IS-700
    6. IS-800
    7. IS-315
    8. O-305
41. CERT Class (CERT Applicants Only)
    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).
42. Volunteer Skills

    1. Animal Handling
    2. Volunteer Management
    3. Fundraising or Marketing
    4. Event Coordination / Project Mgmt
    5. Database Management
    6. Website or Social Media Mgmt
    7. Public Relations
    8. Grant Writing
    9. Disaster Response
44. Medical Certifications and Qualifications

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

    1. CPR / First Aid
    2. EMR
    3. EMT
    4. AEMT
    5. Paramedic
    6. LPN
    7. RN
    8. Nurse Practitioner
    9. Physician Assistant
    10. Physician
    11. Registered Vet Tech
    12. Veterinarian
    13. Mental Health Counselor
    14. Social Worker
    15. Dentist
    16. Epidemiologist
45. 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).

    1. Firefighter I
    2. Firefighter II
    3. HazMat Awareness
    4. HazMat Operations
    5. HazMat Technician
    6. Trench Rescue
    7. Rope Rescue
    8. Confined Space Rescue
    9. Dive Rescue
    10. Structural Collapse Rescue
    11. Swiftwater Rescue
    12. Wilderness Rescue
    13. Wide Area Search Technician
46. Law Enforcement Certifications and Qualifications

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

    1. Kansas Full Time LEO
    2. Kansas Part Time LEO
    3. Kansas Auxiliary LEO
    4. Arson / Explosive Investigator
    5. Crime Scene Technician / Investigator
    6. Crisis Negotiator
    7. Drug Recognition Expert
    8. Forensic Tech / Scientist
    9. Hazardous Devices Tech
    10. Animal Control Officer
48. Other Certifications and Qualifications

    Mark any additional active certifications or qualifications that you possess.

    1. Amateur Radio: Technician
    2. Amateur Radio: General
    3. Amateur Radio: Extra
    4. COML
    5. COMT
    6. KCEM or CEM
    7. Commercial Driver's License: Class A
    8. Commercial Driver's License: Class B
    9. Commercial Driver's License: Class C
49. Other Notable Skills or Credentials
    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.
51. Amateur Radio Call Sign
52. List any other languages that you read, write or speak fluently:
54. Membership Level (CERT applicants only)

    CERT members are asked to select a membership level that best matches their ability to participate or availability to respond to activations. (Contact us for more information on membership requirements.)

    1. Level 1 (fewer credentialing requirements, but some limitations on roles members can fill or opportunities available)
    2. Level 2 (more credentialing requirements, but more roles and opportunities are made available to these members)
55. Participation Options (CERT applicants only)

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

    1. Deployment and Public Service Group (includes disaster response, storm spotting, Operations Center Support, traffic/perimeter control)
    2. Training and Public Outreach Group (arranges, delivers and/or supports training opportunities for the team or outreach/education events for the public)
    3. Communications Group (supports the team's communications needs through, but not limited to, amateur radio operations)
57. Other Information*

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

    1. Yes
    2. No
58. Provide details of any criminal or traffic offenses:
60. 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.

    1. Agree
62. Questions?
    If you have any questions related to the application, please contact Butler County Emergency Management at (316) 733-9796.
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field