Jefferson
C/O
Charles
304-728-3329
Community Emergency Response Team (CERT)
Please tell us about yourself.
This information will help us to make your learning experience most
fulfilling. Thank you!
Name: Title:
Address:
Daytime Phone Number
Evening Phone Number
Cell Number
Email Address:
I prefer to take my
CERT Class during ________
daytime _________evenings
Date of Birth (Month, Day, Year) __________________________
Where do you work?:
Duties &
Responsibilities:
Time in Emergency
Management (if any):
Career background:
Emergency responder
experience (if any):
Purpose for
participating in this course:
Goals for this
experience:
Do you have any
allergies (food, chemical or textile)?
Do you have any
special needs to facilitate your participation in this course?
How do you want your name to appear on your certificate? _____________________
I understand that I must always work with a buddy, that
before I go into an area of possible danger that we will do a size-up of the
situation. If determined safe to enter
after our size up, we will do so together.
I will always wear my hardhat, my vest, my work gloves, my goggles and
my boots when working in an emergency area.
I understand that I am NOT an emergency responder and I will not attempt
to exceed my training in any situation.
I
understand that I am required to complete any and all required NIMS (National
Incident Management System) Requirements.
Currently, this includes completion of the following courses available
on-line:
IS-700, NIMS; IS-800 National Response Plan, IS-100 Basic Incident
Command, IS-200 Incident Command.
I understand that I am participating in this training as a volunteer and that I must attend all 8 classes plus the final exercise in order to receive a certificate of participation.
I understand that by becoming a member of CERT, I am also becoming a part of the larger organization, the Jefferson County Office of Homeland Security Partners.
I agree that myself or my heirs to
hold harmless the instructors of this course, Jefferson County CERT, and/or the
Jefferson County Commission for any injuries that I may sustain while
participating this course. I certify
that I am over 18 and understand that I will need to bring a photo ID with me
to the first class.
Upon the completion of this class, a
data-base of all participants that are awarded a certificate of participation
will be made available to all emergency responder agencies in the county, to
the local office of emergency management, and to agencies that may call me to
ask me to participate in activities.
You will need to wear sturdy
shoes or work boots to every class. You will also need to wear loose comfortable
clothing. No shorts. No bare arms.
If you have long hair, we strongly suggest that it be tied up during
class.
Your safety and the safety of the
other students and instructors is the number one priority of your instructional
team. If at any time
you see something that is unsafe or if you feel uncomfortable doing any of the
participating exercises, please notify your instructor or course manager
immediately. If you are
physically unable to do any of the exercises within the course, please notify
your instructor BEFORE you attempt to do the exercise.
___________________________________ ____________________
Signature
Date