Fillable Carter County CERT (Community Emergency Response Team) Hold

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Carter County CERT (Community Emergency Response Team) Hold

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CCCERT Membership Application
6/28/2016 REV 3.0
Carter County CERT
(Community Emergency Response Team)
Hold Harmless Agreement
Printed Name: _____________________________________________________________________________
Phone #: ____________________________________ Cell #: ______________________________________
I, the individual named above, hereby request permission to participate in the Carter County Community
Emergency Response Team (CERT) Program and am 18 years of age, or older. I understand that response and
training will involve physical participation, which includes a potential risk of personal injury and/or personal
property damage. I make this request with full knowledge of these risks. Further, I have read and understand
the Program outline that describes the training and associated activities (a complete description is available at
www.citizenscorps.gov/cert/
).
I agree to indemnify and hold Carter County, the Carter County CERT, Carter County Emergency Management,
and each of their officers, governing bodies, agents, employees, personnel, and volunteers, harmless from any
and all claims, actions, or suits for any injury or loss that I may suffer, or which may arise, as a result of my
participation in the above mentioned Program. I understand that personal safety is the foundation of the Carter
County CERT and agree to follow the code of conduct, rules, and policies established by Carter County
Emergency Management, the Carter County CERT, CERT leadership and instructors, and to exercise
reasonable care while participating in the CERT Program.
I understand that I can be administratively removed from the Program at any time. Additionally, I authorize the
use of my image, photographed in connection with my participation in the Program, without prior approval or
compensation. I understand that my submission of this application, whether mailed, or sent electronically via
email, or faxed, will have the same force and effect as an original. Further, I understand that a background
check will be required for all applicants, and my acceptance into the Program is subject to clearance of the
background check.
I authorize Carter County Emergency Management to require a background check, including a check of
criminal records, and other information regarding me, that may be of a confidential nature. I understand that the
background check results do not have to be disclosed to me. By executing this release, I certify that I have read
this release in its entirety, understand all of its terms, and have had any questions regarding the release
satisfactorily answered. I sign this release freely and voluntarily.
Signature: ________________________________________ Date: __________________________________
CCCERT Membership Application
6/28/2016 REV 3.0
Carter
County
Community
Emergency
Response
Team
Volunteer Application
Please complete and return to:
Carter County Emergency Management
107 1
St
Ave SW Ardmore, OK 73401
APPLICANT INFORMATION:
First Name:
M.I.:
Last Name:
City:
State:
Zip:
Home Phone:
Work Phone: (Can you be contacted at
work?)
Cell Phone:
Email Address:
Cell Phone Carrier
Date of Birth:
(MM/DD/YYYY)
Valid Driver’s
License? (Y/N)
State of
Issue:
DL#:
SSN:
Are you an Amateur Radio Operator? Class of License: Call Sign:
Are you presently
employed? (Y/N)
Full or Part Time?
Name and Address of Employer:
Have you ever been convicted of a crime? YES NO
You may omit: a) Traffic violations, (Driving Under the Influence convictions must be reported); b) Any conviction committed prior to your 18
th
birthday which was
finally adjudicated in Juvenile Court or under a youth offender law.
EMERGENCY CONTACT INFORMATION:
Name:
Address:
Phone:
Relation:
Please Provide Two Personal or Professional References:
Name
Address
Phone
1.
2.
If you have a disability, what accommodations would you need to do this volunteer position?
Are there any certain skills, training or knowledge you wish to utilize with CCCERT?
I authorize investigation of all statements contained in this application and any supporting documents
and I understand that a background check, criminal history and driver’s license check will be conducted.
I authorize Carter County Emergency Management, Carter County Community Emergency Response
Team, and its non-profit partners to secure information from the references I have provided, and release
all parties from any liability arising from such investigation.
Signature of Applicant:
Date
CCCERT Membership Application
6/28/2016 REV 3.0
Name: ____________________________________________________________________
Use this form to supply areas of interest. You may check multiple areas.
Please check Interest for the following:
___*CPR (Check if certified )
___*First Aid (Check if certified )
___ *Nurse
___Foreign Language (Please List) _________________________________________
___Sign Language
___Computer Data Entry
___Clerical—Typing
___Search and Rescue
___Shelter Management
___Weather Spotter
___Radio Operator
___Exercise Planner
___Exercise Participant
___Administrative
___Traffic Control
___Speaker on Preparedness Topics at Community gatherings.
___Give slide or film presentations in schools and businesses.
*For all areas of interest with qualifications, please provide a copy of the certification.
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Carter County CERT (Community Emergency Response Team) Hold

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Completed 5 December 2021

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