CITY OF GLENN HEIGHTS VOLUNTEER EVENT REGISTRATION
FORM
Learn how you can help yourself, your family and your community during a disaster. Community
Emergency Response Team (CERT) members are groups of active residents that receive special
training for the purpose of enhancing their ability to recognize, respond to, and recover from a major
emergency affecting the Glenn Heights community. The CERT program educates our citizens on
disaster preparedness, such as fire safety, light search and rescue, team organization and disaster
medical operations.
Glenn Heights is actively recruiting residents to be trained for this program. To become a member of the
City of Glenn Heights C.E.R.T. Program, send us your name, address, home phone, cell phone, and
email address in the form below. Participants must be 18 years of age and pass a background check to
be accepted. We'll get you signed up for upcoming meetings and training.
First Name: Last Name:
Email Address:
Phone Number:
Address:
Glenn Heights, Tx. 75154
Emergency Contact: Emergency Phone:
T-shirt Size:
Small
Medium
Large
X-Large
XX-Large
Do you have any allergies? Yes No
If yes, please explain:
The City of Glenn Heights Consumer Report Disclosure Form
The City of Glenn Heights may, with your consent, obtain a consumer report (as defined by the Fair Credit Reporting Act),
related to your prospective, current, or future employment. This may include procurement of an investigative consumer
report (defined as a report that includes
information as to your character, general reputation, personal characteristics, or
mode of living).
You may request that the nature and scope of any investigative consumer report be disclosed to you. Such disclosure will be
made within 5 days of our receipt of the request from you or five days after the date the investigative consumer report
was
first requested, whichever is later.
By signing below, you grant permission to The City of Glenn Heights or any of its affiliated or subsequent companies to
obtain such report or reports at any time. You also grant permission to all parties to release information regarding your
previous or current military service, employment, education, or criminal matters,
including information which may be
deemed negative.
____________________________________ ____________
Signature Date
Identity Information
First Name:
Middle Name:
Last Name:
Current Address:
City: State: Zip:
Other Names Used (Maiden or Aliases):
Social Security Number:
Driver’s License Number: State:
Date of Birth: Month: Day: Year:
Please list each city/county and state in which you have lived, worked, or attended school during the last ten (10)
years. Use the back of this form if necessary to provide full disclosure.
City: County: State:
City: County: State:
City: County: State:
City: County: State:
City: County: State:
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WAIVER
I do hereby authorize a review and a full disclosure of any and all records concerning myself to any duly
authorized agent of the City of Glenn Heights, whether said records are of public, private, or confidential
nature. The intent of this authorization is to give my consent for full and complete disclosure of my work
record, school record, my reputation, or my financial and credit status. You may include all my medical,
physical and mental records or reports including all information of a confidential or privileged nature, and
photocopies of the same if requested. This information is to be used to assist the City of Glenn Heights in
determining my qualifications and fitness for the position I am seeking.
I hereby release you, your organization or others from any liability or damage, which may result from
furnishing the information requested above.
Signature of Applicant Date
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signature
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