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2. 

3. Summit County CERT Registration Form

5. SUMMIT COUNTY CERT REGISTRATION
   7 WEEK CERT TRAINING PROGRAM
   

   
   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.
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.
101. Agree

     1. Yes
102. Signature of Applicant
103. Date
     Date
Leave This Blank:


105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit

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