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CERT (Community Emergency Response Team) Enrollment Form

  1. Ashfield Community Emergency Response Team

    Enrollment Form

  2. 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.

  3. CERT - 03 - 296x296
  4. 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.

  5. Residence physical address not a mailing address.

  6. Cell Phone?*
  7. How long have you lived in MA? Round to the nearest year count.

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

  9. Employment and Service History
  10. Military Service*

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

  11. Which branch of the US Military?

  12. 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:

  13. Experiences and Skills
  14. Disaster Training*

    Do you have any disaster related training or experiences? 

  15. Describe your disaster related training.

  16. Medical Training*

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

  17. Describe your other or additional medical training.

  18. Emergency Training*

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

  19. Provide explanation or details on other emergency training received.

  20. Skills*

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

  21. Provide a description of your other skills.

  22. Additional Information
  23. 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.

  24. Criminal Record*

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

  25. 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:

  26. Leave This Blank: