COMMUNITY EMERGENCY RESPONSE TEAM 

Course Completion Interest Survey 

Congratulations on completing the CERT course and thank you for your willingness to invest your time and resources in making our community better prepared to respond to disasters of any type.  Now that you have completed the course it is important for us to understand your wishes regarding future involvement with the CERT program, as individuals take this training course for many different reasons:

	To learn how to provide care for family and friends 

	To provide disaster assistance in a specific neighborhood or workplace

	To be part of a community-wide or regional disaster response team

Your wishes and intentions regarding any future involvement with CERT are of the utmost importance to us.  Please assist us by indicating your preferences below:

NAME:_________________________________________________DATE:______________________
                                                                                                                                                                                                    Course Completed
	I would like to become part of an organized CERT disaster response team, and participate in future training 		opportunities and team activities

	I do not wish to be part of a response team, but I would like to participate in additional training and/or 			continuing education opportunities

	I am interested in learning more about becoming a CERT instructor

	I have benefited from the course, but do not wish to participate in future activities

If you wish to receive future CERT information, please indicate preferred contact address below:

E-MAIL:______________________________________________________________________

ADDRESS:____________________________________________________________________

CITY:_____________________________________   ZIP:______________________________

PHONE:___________________________________  ALT #_____________________________


COMMENTS/INTERESTS:________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Signed:________________________________________________________________________