CERT Registration Form

2. 

3. Summit County CERT Registration Form

5. SUMMIT COUNTY CERT REGISTRATION
   7 WEEK CERT TRAINING PROGRAM
   

   Class begins: APRIL 18, 2018

   
   Summit County Health Department
   650 Round Valley Road
   Park City UT 84098

   
   

   Cost: $35.00 includes all course materials, CERT back-pack and personal protection equipment

7. THIS INFORMATION IS CONFIDENTIAL AND IS DISTRIBUTED ONLY FOR USE IN CONNECTION WITH THE DEVELOPMENT AND IMPLEMENTATION OF THE CERT PROGRAM.

9. Please clearly print the information below, as you would like it to appear on your certificate.

13. First Name

14. Last Name

16. Physical Address

18. City

19. State

20. Zip

22. Is your Mailing Address same as your Physical?

    1. Yes
    2. No

24. Mailing Address

26. City

27. State

28. Zip

30. Neighborhood / Development

34. Contact Info:

36. Cell #

37. Provider

39. Home #

40. Fax #

42. Work #

43. HAM #

45. Email

49. Employment:

51. Occupation

52. City Where You Work

54. Training / Skills

55. Certifications

57. Training / Skills

58. Certifications

60. Training / Skills

61. Certifications

65. Languages:

67. Primary

68. (Check all that Apply)

    1. Speak
    2. Read

    1. Write

70. Second

71. ( Check all that Apply )

    1. Speak
    2. Write

    1. Read

73. American Sign Language

    1. Yes

    1. No

77. Emergency Contact

79. First Name

80. Last Name

82. Contact Phone #

83. Relationship to you

87. Hold Harmless Agreement

89. By signing this Application I understand that in the event of an injury during a CERT activity or a community disaster, I will need to rely on my own Personal Insurance and not the Summit County Government, it's agents, or the Summit County Community Emergency Response Team for any redress or payment. I further agree to adhere to my training to stay and act within my training, to abide by and follow the direction given to me by members of the Emergency Services of Summit County, it's agents, or Team Leaders for the Summit County CERT.

    By signing this Application I understand that in the event of an injury during a CERT activity or a community disaster, I will need to rely on my own Personal Insurance and not the Summit County Government, it's agents, or the Summit County Community Emergency Response Team for any redress or payment. I further agree to adhere to my training to stay and act within my training, to abide by and follow the direction given to me by members of the Emergency Services of Summit County, it's agents, or Team Leaders for the Summit County CERT.

91. Agree

    1. Yes

92. Signature of Applicant

93. Date
    Date

97. Ethics & Standards Agreement

99. As a CERT Member I will follow all CERT training practices and continue my CERT Skills thru Refreshers courses, In‐Service meetings, and to volunteer 12 hours of my time a year (continuing education, events, and exercises) in my community. I will endeavor to work within the "Buddy System", and to "Evaluate", and "Size‐Up" situations to keep my‐self, my neighbors, and my community safe within my abilities. I understand that following my training and volunteering in my community will contribute to faster recuperation after a disaster. As a CERT Member I will prepare myself physically, morally, and mentally to work as a volunteer for myself, my neighbors, and my community. I understand that there are no limitations in physical ability, race, gender, or religious preference in CERT, and that I will treat all people with dignity, honesty, and respect. In a Disaster I will communicate disaster conditions to my immediate CERT Supervisors, or the proper civil authorities as situations arise, including providing applicable documentation. I will use and wear my PPE (Personal Protective Equipment) appropriately, and responsibly in our community. I will not "Self Activate" with out proper notification, but will prepare myself, my family. neighborhood, and then make myself available if the situation is warranted at the designated assembly points in our community. I will comport myself to the best of my ability knowing that I represent The CERT Program in my community. I will assist the CERT Program in updating my contact information when changes occur. I further understand that some volunteer and/or Leadership opportunities may be closed to me as a General CERT Member, and that to expand my roll in CERT Responsibilities I will have to meet the requirements for a Credentialed CERT Team Member.

    As a CERT Member I will follow all CERT training practices and continue my CERT Skills thru Refreshers courses, In‐Service meetings, and to volunteer 12 hours of my time a year (continuing education, events, and exercises) in my community. I will endeavor to work within the "Buddy System", and to "Evaluate", and "Size‐Up" situations to keep my‐self, my neighbors, and my community safe within my abilities. I understand that following my training and volunteering in my community will contribute to faster recuperation after a disaster. As a CERT Member I will prepare myself physically, morally, and mentally to work as a volunteer for myself, my neighbors, and my community. I understand that there are no limitations in physical ability, race, gender, or religious preference in CERT, and that I will treat all people with dignity, honesty, and respect. In a Disaster I will communicate disaster conditions to my immediate CERT Supervisors, or the proper civil authorities as situations arise, including providing applicable documentation. I will use and wear my PPE (Personal Protective Equipment) appropriately, and responsibly in our community. I will not "Self Activate" with out proper notification, but will prepare myself, my family. neighborhood, and then make myself available if the situation is warranted at the designated assembly points in our community. I will comport myself to the best of my ability knowing that I represent The CERT Program in my community. I will assist the CERT Program in updating my contact information when changes occur. I further understand that some volunteer and/or Leadership opportunities may be closed to me as a General CERT Member, and that to expand my roll in CERT Responsibilities I will have to meet the requirements for a Credentialed CERT Team Member.

101. Agree

     1. Yes

102. Signature of Applicant

103. Date
     Date

Leave This Blank:


105. 1. Receive email copy
106. Email address

     This field is not part of the form submission.

107. Submit

* indicates a required field