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Online CERT Application

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Steps

1. Page 1 This section is complete This section is incomplete
2. Page 2 This section is complete This section is incomplete

Page 1

Community Emergency Response Team Application
Last Name*
First Name*
Middle Initial
Address*
City or Town*
State*
Zip*
Home Phone
Work Phone
Cell Phone
Email Address*
Do you have any disabilities?*
1. Yes
2. No
Please list any accommodations needed
Please list any special talents, skills, abilities, and / or certifications that you have
Emergency Information
In case of emergency, person to contact should be:
Name*
Relationship*
Address*
City*
State*
Phone Number*
Continue

Page 2

Background Information
Date of Birth*
Date of Birth
Last 4 Digits of Social Security #*
Driver's License #*
State*
Type
Expiration Date*
Expiration Date
Have you ever been convicted of a felony crime?*
1. Yes
2. No
Your Signature*
Do you consent to using an electronic signature?*
1. Yes
2. No
Today's Date*
Today's Date
Disclaimers
EQUAL OPPORTUNITY STATEMENT
The Town of Rocky Hill, Connecticut does not discriminate on the basis of age, sex, race, color, religious belief, national origin, or disability in their admission.
PRIVACY ACT STATEMENT
General – This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals applying for admission to the Rocky Hill CERT Program.
Authority – 5 U.S.C.301; 15 U.S.C. 2206; 44 U.S.C. 3101; 50U.S.C. App. 2253 and 2281; E.O. 12127, 12148 and 9397; Title VI of the Civil Rights Act of 1964; and section 504 of the Rehabilitation Act of 1973
Purpose – To determine eligibility for participation in the Rocky Hill CERT program.
Uses – Information may be released to Federal Emergency Management Agency (FEMA) staff to analyze application and enrollment patterns for specific courses and to respond to student inquiries; and to a physician to provide medical assistance to CERT members who become ill or are injured during courses or operations.
Effects of Nondisclosure – Personal information is provided on a volunteer basis. Failure to provide information on this form, however, may result in a delay in processing your application and / or certifying completion of the program.
(All information is kept confidential)