Fillable CERT Application PDF Untitled (Town of Davie)

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CERT Application PDF Untitled (Town of Davie)

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  • 9 check-boxes
  • 21 other fields

Country of origin: US
File type: PDF

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Town of Davie CERT
Volunteer Application
A Volunteer Application must be completed for an applicant to be considered to volunteer at the
Town of Davie. Please answer each question. If the question does not apply, indicate N/A. If the
space
available is insufficient, please attach additional sheets as required. Please PRINT
CLEARLY in ink or TYPE all information.
Name (Last, First, MI):
Address:
Development Name:
City:
State: Zip:
Home Telephone:
Cellular:
Email Address:
Driver’s License/State ID Number:
List any current or past civic/community organization affiliation/s:
Place of Employment:
Why are you interested in CERT training?
Emergency contact information:
Name:
Telephone Number:
Address:
City State/Zip
I AM AWARE that volunteering for the Town of Davie involves risk of personal injury, property
damage, and other risks associated with volunteer service.
I RELEASE the Town of Davie and the Davie Fire Rescue Department from any and all liability for
all loss, damages, and claims, (including attorney fees and costs), resulting from injury to the person
listed below or to his or her property arising from the volunteering services.
I HEARBY HOLD HARMLESS the Town of Davie, Davie Fire Rescue and project organizers from
any and all claims, actions or damages relating to or arising out of any activity related to
volunteering for the Town of Davie.
These releases are effective for the applicant listed below, his or her personal
representatives, assigns, heirs, guardians.
I HEARBY confirm, represent and warrant that I have never been convicted of any violent crime,
child abuse or neglect, child pornography, child abduction, kidnapping, rape of or sexual offense of
any kind or any other violation of law, nor have I ever been ordered by a court to receive psychiatric
or psychological treatment in connection therewith.
I UNDERSTAND I am fully and completely responsible for all healthcare expenses incurred by me if
I become injured while participating in the Town of Davie’s Volunteer Program, and I have made
arrangements to handle such expenses through insurance coverage, access to cash, or other
methods.
FURTHERMORE, I agree to utilize my own vehicle for transportation to and from the Town, and
further agree that I will be fully responsible for any and all damages or injuries sustained by myself
and anyone else in my vehicle. I agree not to provide transportation for any of the children that are
attending any of the programs for which I volunteer. I hereby represent and warrant that I am fully
insured to operate my personal vehicle, to the extent required by law.
I ASSUME FULL RESPONSIBILITY FOR any and all claims and costs (including my own) arising
directly or indirectly out of activities, acts, or omissions while volunteering for the Town of Davie.
FUTHERMORE, I authorize the Town of Davie and Davie Fire Rescue Department to use my name
and give any organization involved with the Town of Davie permission to photograph me. I
understand that the Town of Davie has permission to use my name, photographs/videotapes,
likeness, image, voice or biography in all media, publications, advertising and publicity purposes in
connection with my participation with The Town of Davie Volunteer Program related activity or
project unless written notice is received to the contrary.
I CERTIFY that the statements made in this volunteer application are true and correct, and
have been given voluntarily. I understand that this information may be disclosed to any
party, with legal and proper interest, and I release the Town of Davie and Davie Fire Rescue
Department from any liability whatsoever for supplying such information. I understand that a
volunteer is not any employee of the Town of Davie and I will not be paid for services in this
capacity.
I have carefully read and understand completely the above provisions and voluntarily sign the
release and indemnity agreement.
Prin
t Full Name
Si
gnature Date
The application can be faxed to 954-797-1234 or mailed / delivered to Davie Fire Rescue, Attention
CERT,
6901 Orange Drive, Davie FL 33314 If you have any questions please call 954-797-1213
The Town of Davie reserves the right to accept or reject any CERT applications
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CERT Application PDF Untitled (Town of Davie)

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Completed 14 July 2020

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