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Clayton Police Department

6000 Heritage Trail
Clayton, CA 94517
925-673-7350

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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.



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