2. Ashfield Community Emergency Response Team

   Enrollment Form

4. Any and all residents of the Town of Ashfield, 18 and older, may apply for membership to the Ashfield Community Emergency Response Team (CERT) for a period of two years. Membership is voluntary and does not offer payment or fringe benefits. Applicants agree to a Criminal Offender Record Information (CORI) check upon application. Membership may be dependent upon the outcome of this CORI check and are contingent upon successful completion of the CERT Training Program.

   This is merely an enrollment form. Once a sufficient number of interested potential volunteers have enrolled the process of creating  an Ashfield CERT shall proceed.  A membership application will be required. Background check will be done, and training will be scheduled.

   For questions or further clarification contact the Emergency Management Director (EMD) George Stephan at emd@ashfield.org or at 413-628-4441 Ext: 9.

5. 
7. First Name*
8. Last Name*
9. Middle Initial
11. Date of Birth*
16. Residential Address

    The address below must be your resident physical address. If you have a PO Box please enter it as well in case we send out mailers.

18. Street Address (Name and Number)*

    Residence physical address not a mailing address.

19. City*
21. Ashfield PO Box/Address (if appllicable)
22. State*
23. Zip*
25. Phone Number*
26. Cell Phone?*

    1. Yes
    2. No
27. Email Address*
29. Years in the State of MA*

    How long have you lived in MA? Round to the nearest year count.

30. Years in Franklin County?*

    How long have you lived in Franklin County? Round to the nearest year count.

34. Employment and Service History
36. Occupation*
37. Employer*
39. Military Service*

    1. Yes
    2. No

    Have you served with any branch of the United States Military?

40. Branch

    Which branch of the US Military?

42. Clubs and Organizations

    Are you a member of a Neighborhood Crime Watch, Homeowner’s Association, or any other organization/club, please indicate the name of the group and its president:

46. Experiences and Skills
48. Disaster Training*

    Do you have any disaster related training or experiences? 

    1. Yes
    2. No
49. Disaster Training Details

    Describe your disaster related training.

53. Medical Training*

    Have you received training in any of the below listed medical fields? 

    1. First Aid
    2. CPR
    3. EMT
    4. Other (provide details)

    1. Paramedic
    2. LPN
    3. RN
    4. None of the above
54. Medical Training Details

    Describe your other or additional medical training.

58. Emergency Training*

    Have you received training in any of the below listed emergency fields/topics?

    1. Incident Command (ICS)
    2. Fire Fighting
    3. Fire Suppression
    4. Law Enforcement

    1. Search & Rescue
    2. Disaster Preparedness
    3. Damage Assessment
    4. HazMat

    1. Weather Emergencies
    2. Wilderness Survival
    3. Communications
    4. Other (provide details)

    1. Record Keeping
    2. Shelter Management
    3. Ham Radio
    4. None of the Above
60. Emergency Training Additional Details

    Provide explanation or details on other emergency training received.

64. Skills*

    Select all skills that apply. Please add details or specifics in the comment section.

    1. Clerical
    2. Animal rescue/handling
    3. Transportation

    1. Heavy equipment
    2. Chainsaw
    3. Other (additional info)
65. Other Skills Details

    Provide a description of your other skills.

69. Additional Information
71. Physical or Medical Restrictions*

    Do you have any physical or medical restrictions that might affect your participation in some of the exercises used in the CERT training/courses? if yes please explain in the explanation section.

    1. Yes
    2. No
72. Physical or medical restrictions explanation
76. Criminal Record*

    Have you ever been convicted of a felony? If yes please provide an explanation.

    1. Yes
    2. No
77. Criminal record explanation
81. Are You in BlackBoard Connect System?

    Are you in the Town's phone broadcast system? If not we encourage all residents to enroll in it especially members of CERT.

    If you would like to add your name or make changes in it add/Select the type of Robo Calls action you are requesting from the following options:

    1. Add to the list

    1. Change information

    1. Remove from the list
85. Additional information or comments
Leave This Blank:


91. Submit

* indicates a required field