Volunteer Redistration Form

Welcome
	Citizen Guide
	Training Calendar

Affiliates
	SRC Volunteer Center
	Ready.gov
	SRC Communications Service
	American Red Cross
	Santa Rosa 4H

National Organizations
	National CERT
	Fire Corps
	Teen CERT
	National Citizen Corps
	Medical Reserve Corps
	USAonWatch.org
	VIPS

Volunteer Redistration Form

Thank you for your interest in becoming a Santa Rosa County Citizen Corps volunteer. As a volunteer you will have the opportunity to be involved in citizen participation in homeland security related efforts.

Name

First Name:

MI:

Last Name:

Address and Contact Information

Street:

Apt Number:

City:

County:

State:

Zip Code:

Home Phone:

Work Phone:

Best time to call:

Email Address:

Languages Spoken:

Other Information

Are you a Veteran?

Occupation/Profession:

Would you be interested in facilitating training classes once you are trained?

Have you had any type of first responder training in the past?

If so, what type and when:

Have you visited the Citizen Corps Website?

How did you hear about Citizen Corps?

Skills and Interest check all that apply:

Computers:	Disaster Recovery
Graphic Art:	Construction
Web Design	First Aid
Public Speaking	CPR
Community Interaction	Crime Prevention
Teaching	Fire Safety
Disaster Preparedness	Water Safety
Media Interaction
Volunteer Oppertunity check all that apply:
Fire Corps	CERT
Medical Reserve Corps	Volunteers in Policing
Neighborhood Watch	Amateur Radio
Red Cross	4H
Any volunteer opportunities

Any Other Interest or Skills:

When could you begin volunteering?

Information contained herein is for Citizen Corps purposes only. Citizen Corps will not divulge any personal information to any person or agency.