City of Hampton, Division of Fire and Rescue

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CERT Class Application Form

By completing this application in its entirety, you will help the CERT instructors understand the general profile of the class they are teaching. Submitting an application does not guarantee admittance to the next scheduled class. However, it does assure that your interest is recorded and you will be notified of the next available class. The information provided will not be shared with parties outside the City of Hampton Division of Fire & Rescue and the CERT Program.

*Last Name:

*First Name:

*Middle:

*Date of Birth (month/day/year):

*Address:

*City:

*State: *Zip:

Mailing Address (if different than above):

City:

State: Zip:

*Home Phone Number:

*Work Phone Number:

*E-mail Address:

*Occupation:

*Name of Sub-Division (Neighborhood):

*Will you be training with a group?:

Yes

If yes, with what group will you be training:

*Have you ever completed a Basic first Aid course?:

Yes

CPR Course:

*Are you a licensed amateur radio operator?:

Yes

Call Sign:

Class:

*Do you have any disaster-related training or experience?:

Yes

If yes, please describe:

*Are you available to attend all nine classes to obtain a FEMA certificate of participation?:

Yes

*Are you able to perform the essential requirements of this program with or without Accommodation?:

Yes

Person to notify in case of emergency:

Relationship:

Phone Number:

Enroll Me in This Class:

Enroll Me in a Future Class:

In consideration of the City of Hampton granting permission for me to participate in its Community Emergency response Team training program, I hereby waive all claims for damage or loss to my person and property that may be caused by any act, or failure to act on the part of the City, its agents, officers, employees and representatives. I assume the risk of all dangerous conditions in and about the training premises as well as any risk of injury present in training program activities and waive any and all specific notice of the existence of any such conditions or risks.

This agreement is voluntarily given and executed by clicking the submit button.