Registration
Northern Sonoma County Community Emergency Response Team
Cloverdale & Northern Sonoma County Fire Protection Districts
Adult CERT – Training Application Agreement and InformedConsent
Last Name: First Name: Ml: Address: City: Zip: Email: Date of Birth:
Home Phone: ( ) Cell Phone: ( ) Sex: _ Work Phone ( ) Driver’s License No.: Occupation: _
I the undersigned agree to participate in the “Adult CERT Training Program.” This program is a FEMA approved Community Emergency Response Training Program designed to target the adult population interested in disaster services and volunteerism. The Northern Sonoma County CERT Program is sponsored by the Northern Sonoma County Community Emergency Response Team (CERT) and Cloverdale and Northern Sonoma County Fire Protection Districts.
- This program consists of nine (9) training modules that will be delivered to you.
- CERT will provide knowledge based on an all hazard approach to mitigation, preparation, response, and recovery from a technical and natural disaster. CERT will build decision- making and problem-solving skills and strategies to help volunteers make informed decisions regarding readiness, response & recovery and mitigation efforts to reduce loss of life and property in a disaster.
- CERT will provide volunteers with hands-on training using reality-driven drills and exercises.
- Specially trained, primary responders will participate in the classroom lessons. The responders range from Adult CERT Trainers, Emergency Medical, Search and Rescue, Law Enforcement, Firefighting and Emergency Management Personnel.
As with all programs, there lies a slight risk of injury from hands-on participation.
I understand that any medical bills are my own responsibility. I agree to hold Cloverdale Emergency Response Team (CERT), Cloverdale and Northern Sonoma County Fire Protection Districts, and other agency volunteers involved in this program harmless from all claims that might come from participation in this program.
I understand that I will be asked to participate in a short, voluntary and confidential survey during the first week of the program and again near the last day of the program. Answers will be private, and the surveys will not record my name or any other identifying information. These forms will be completed in private. The purpose of these surveys is to evaluate your knowledge of disasters in a pre-post assessment of the program. This information is also needed to assure that programs such as this continue to be available in the community. You have a right to view the blank survey forms. If you do not wish to answer any or all the survey questions you need only to leave blank any question(s) you do not wish to answer.
Northern Sonoma County Community Emergency Response Team
Cloverdale Fire Protection District
I understand that I am expected to attend all scheduled sessions. If needed, makeup classes can be schedule for a limited number of people and a limited number of modules but I understand that I might need to take the Basic Course again at a different time if I miss more than one module of instruction.
I understand that Northern Sonoma County CERT will provide staff members to supervise all program sessions, and that others may visit the program during any program session as observers.
Publicity
Photographs, or video tape recordings of participants involved in the Northern Sonoma County CERT Program may be used by staff for publications or advertising materials. In addition, local news organizations may hear of our activities and we would like to extend our invitation to photograph or record our activities. This consent includes, but is not limited to: photographs, videotape, and audio recordings.
This training is purely voluntary, and you may at any time opt out of the training without any repercussions.
This program has been reviewed and approved by Cloverdale Emergency Response Team, and Cloverdale and Northern Sonoma County Fire Protection Districts. If you have any questions regarding the approval process, please contact either Geoffrey Peters, Adult and Teen CERT Program Manager (301-675-7741) or Chief Jason Jenkins, Cloverdale Fire Protection District (707-894-3545) or Chief Marshall Tuberville (707-857-4373).
I have read the above document and agree to the guidelines set forth in this document.
Signature
Date
Northern Sonoma County Community Emergency Response Team
Cloverdale & Northern Sonoma County Fire Protection Districts
Your name:_
Please list any law enforcement, fire services or disaster related training or experience you have:
Please list any special skills you have that might be relevant (e.g. heavy equipment operation, nursing or medical skills, search and rescue training, etc.)
Emergency Contact #1 (Relationship)
Last Name: First Name: Ml:
Phone Home: Cell: Business:
Emergency Contact #2 (Relationship)
Last Name: First Name: Ml:
DISASTER SERVICE WORKER REGISTRATION
LOCAL AND STATE INFORMATION
Loyalty Oath under Code of Civil Procedure §2015.5 & Title 19, Div.2, Chap.2, Sub-Chap.3, §2573.1
TYPE OR PRINT IN INK (HIGHLIGHTED AREAS REQUIRED BY PROGRAM REGULATIONS)
NAME: LAST FIRST MI
SSN:
ADDRESS:
CITY: STATE ZIP:
COUNTY:
HOME PHONE:
WORK PHONE:
PAGER: E-MAIL: DATE OF BIRTH: (optional)
DRIVER LICENSE NUMBER: (if applicable)
DRIVER LICENSE CLASSIFICATION: A B C
OTHER DRIVING PRIVILEGES:
LICENSE EXPIRATION DATE:
PROFESSIONAL LICENSE: (if applicable) FCC LICENSE: (if applicable)
LICENSE EXPIRATION DATE:
IN CASE OF EMERGENCY, CONTACT:
EMERGENCY PHONE:
PHYSICAL
IDENTIFICATION:
HAIR: EYES: HEIGHT: WEIGHT: (optional) BLOOD TYPE:
(optional)
COMMENTS:
Government Code §3108-§3109:
Every person who, while taking and subscribing to the oath or affirmation required by this chapter states as true any material matter which he knows to
be false, is guilty of perjury, and is punishable by imprisonment in the state prison not less than one nor more than 14 years. Every person having taken
and subscribed to the oath or affirmation required by this chapter, who, while in the employ of, or service with, the state or any county, city, city and
county, state agency, public district, or disaster council or emergency organization advocates or becomes a member of any party or organization, political
or otherwise, that advocates the overthrow of the government of the United States by force or violence or other unlawful means, is guilty of a felony and
is punishable by imprisonment in the state prison.
LOYALTY OATH OR AFFIRMATION (GOVERNMENT CODE §3102)
I, _______________________________________________________, do solemnly swear (or affirm) that I will support and defend the
PRINT NAME
Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the
Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental reservations or purpose of
evasion; that I will well and faithfully discharge the duties upon which I am about to enter. I certify under penalty of perjury that the foregoing is true and correct.
_____________ __________________________________________________________
_______________________________________________________
DATE SIGNATURE IF UNDER 18 YEARS OLD, SIGNATURE OF PARENT/GUARDIAN
________________________________________________________________
_________________________________________________
SIGNATURE OF OFFICIAL AUTHORIZED TO ADMINISTER LOYALTY OATH TITLE