Rev. 03/2016
City of Newport News
Department of Human Resources
Authorization to Release Information
TO: Any Local, State or Federal Law Enforcement Agency; any past or present
employer; any Academic Dean, Registrar, Principal, Guidance Counselor or other
authorized person at any School, College or University; U. S. Armed Forces, or
Maritime services:
(First Name)
(Middle Name)
(Last Name)
(State) (
have applied for employment /volunteer service as a/an
with the City of Newport News, Virginia. I am aware that my entire background
may be investigated thoroughly. I hereby authorize and request the release of any
and all information you have concerning me (including employment and criminal
records) to any representative of the City of Newport News, Virginia, upon
presentation of this release or copy hereof and release all concerned from all
liability in connection therewith.
of Person to be Investigated)
(Place of Birth: State or Country)
(Date of Birth) (Social Security Number)
(Maiden Name) (List any other names or aliases previously used)
(Place of Birth: County or City)
Newport News CERT member Questionnaire Please type or print very neatly.
Name: _______________________________________________________________
Home Phone: _________________________________________________________
Cell Phone: _____________________ Cell phone provider ():________________________
Personal Email: ________________________ Do you receive text messages? ______________
Work Email: ___________________________ Work Phone: _______________________________
Please circle any of your special skills or interests that may be helpful to the CERT:
Forklift operator _____ Veterinarian tech _____ Social Media Skills ____
Military _____ Medical training _____ Project management _____
Emergency Management _____ Training _____
Fluency in other language What Language_______________________________
Other please identify_________________________________________________________________
What CERT activity would you like to participate in? You may choose more than one.
Pet shelter _____ Outreach______
Virtual Ops Support Team____ Logistics______ Point of Distribution Team_____
Please indicate how you learned about the CERT program:
Regional web site ____ City web site ______ State web site ______
TV commercial _______ Friend ______ CERT speaker _______
Other - ________________________________________________________________
Which level of CERT are you interested in? Choose only one:
CERT - B No Deployments, no equipment, no further training. ______
CERT I Can be deployed, on at least one special ops team, equipment issued, attend annual CERTEX,
special ops team training, and 75% monthly drills. _______
CERT A Can be deployed, on more than one special ops team, equipment issued, attend 75% of
course offerings and meetings, leadership training, ICS 100, ICS 200, team leader potential. ______
Memorandum of Understanding
I, (print name)__________________________________________, hereby request to
participate in the Newport News, Virginia Community Emergency Response Team (CERT)
program. I understand that this training will involve active physical participation, which
includes a potential risk of personal injury and/or personal property damage. I make this
request with full knowledge of the possibility of personal injury and/or property damage.
Further, I have read and understand the program outline that describes all class sections
and the associated activities.
I understand that participation in the CERT program may carry a risk of personal injury
and/or property damage. I further understand that I may encounter natural and manmade
hazards, environmental conditions, diseases and other risks that may result in injury to
my person or property. My participation in the CERT program is voluntary. I do hereby
agree to assume all risks which may be associated with or result from my participation in
this program, and hereby waive any and all claims, causes of action and demands
against the City of Newport News, its agents, officers and employees for any personal
injury or property damage arising from my participation in the CERT program.
I agree to follow the rules established by the instructors, and to exercise reasonable care
while participating in the CERT program. I understand that if I fail to follow the
instructor’s rules and program regulations or if I fail to exercise reasonable care, I can be
administratively removed from the program. I understand that I do not become an
employee of the City of Newport News via my participation in the CERT program.
By executing this agreement I certify that I have read this agreement in its entirety,
understand all of its terms and have had any questions regarding this agreement or its
effect satisfactorily answered. I sign this release freely and voluntarily.
____________________________________ _______________________________
Signature Date Print Name
____________________________________ _______________________________
Daytime Telephone Address
____________________________________ _______________________________
Emergency Contact Name Emergency Contact Number
E-Mail Address: _______________________________________________________
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