C.E.R.T. Program Application Return to: 6000 Heritage Trail Community Emergency Response Team Clayton, CA 94517 City of Clayton Phone: 925-673-7350 Clayton Police Department Fax: 925-672-1429 By completing this application in its entirety, you will help the instruction team understand the general profile of the class they are teaching. Submitting an application does not guarantee admittance to the next scheduled class, but it does ensure that your interest is recorded (and you will be notified of the next available classes). 1. Name: ____________________________________________________________________ 2. Address: __________________________________________________________________ 3. City/Zip Code: _____________________________________________________________ 4. Home Phone: ______________ Work Phone: ____________ Cell Phone: ______________ 5. Email Address: _____________________________________________________________ 6. Drivers License Number: __________________ State:______ Expires: ________________ 7. If you belong to a Home Owners Association, please indicate the name of that Association and the President of same: _____________________________________________________________________________ _____________________________________________________________________________ 8. If you do not belong to a Home Owners Association, please state the name of the neighborhood in which you reside: _____________________________________________________________________________ ______________________________________________________________________________ 9. Are you a member of a Neighborhood Watch Program? _____ If yes, which group? ______________________________________________________________________________ 10. Have you ever received training in: (Circle All That Apply) First Aid CPR EMT LPN RN Other Medical ______________________________________________ Incident Command Team Building Psychological First Aid Fire Suppression Law Enforcement Hazardous Materials Search & Rescue Disaster Preparedness Weather Emergencies Wilderness Survival Damage Assessment Communications Other ______________________________________________________ 11. Are you a licensed amateur radio operator? _______ Call Sign:_________ Class: _________ 12. Are you interested in learning more about becoming a volunteer with the Clayton Police Department? ____________________ _______________________________________________ I understand that by completing this course, I will learn certain basic skills that are intended to help me render assistance to others only when I deem it safe and necessary for me to do so. I am under no obligation, by virtue of having received this training, to render aid or become involved in any activities that would make me feel uncomfortable or have the potential to cause me physical or emotional injury. I recognize the fact that I will receive a “Certificate of Completion” only upon attending and completing all seven modules of the course. I agree on behalf of myself, my heirs and assigns to defend, indemnify and hold harmless the City of Clayton and its representatives for any injury or death to persons or damage to personal property arising out of my participation in this program. _____________________________________________________         __________________ Signature                                                                                     Date