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Town of West Hartford

NoReply@WestHartfordCT.GOV

50 S Main, West Hartford, CT, 06107, US

860-561-7500

CERT Application

Please Enter Full Name

Address

    Date of Birth

    Emergency Contact Name

    Typically, what day(s) of the week would you be most likely to serve?

    On the above days, I am typically available

    In consideration for the opportunity to participate in the Town of West Hartford’s Community Emergency Response Team (CERT), I

     

    do hereby agree to the terms listed below:

     

    • The Town of West Hartford has organized a program for the training of volunteer Community Emergency Response Team (CERT) members. The CERT training program is a cooperative activity in which all volunteers must work together to help make the program safe and successful. The program involves instruction in the areas of fire suppression, utility control, first aid, search and rescue techniques, and procedures in organizing emergency response teams to aid and assist the Town in times of crisis. I agree to follow the rules established by the instructors, and to exercise all reasonable care while participating in the CERT program.
       
    • The training program may take place in both indoor and outdoor settings. The training is accomplished primarily in a virtual or classroom setting, although exercises and some training in the use of fire equipment may take place outdoors. The training program involves some physical activity, including carrying equipment and persons and training with fire extinguishing equipment. Team members will not intentionally be exposed to fire or other dangerous situations during their training. I understand that I will perform services and assistance only to the degree that has been covered through my training. I will not perform services or assistance beyond the extent of which I have received proper training.
       
    • Volunteers have the absolute right to choose not to do any activity. I attest that I am in good health, and have no medical or physical limitations or other circumstances that would prohibit me from executing the duties of a CERT member.  I understand that, should I have a medical condition, which could be aggravated by participating in a particular activity, I may opt out of that activity.
       
    • I agree and understand that any work I perform within the scope of this agreement will be provided on a voluntary basis and that I do not expect nor will accept payment or any compensation for performing any work. I also understand that a volunteer position does not constitute any employee – employer relationship with the Town of West Hartford.
       
    • I authorize the use of my image, photographed in connection with my participation in the program, without prior approval or compensation for potential publication by the Town of West Hartford to advertise or promote the CERT program.
       
    • I understand that training will involve active physical participation, which includes a potential risk of personal injury and/or personal property damage; and I apply to volunteer with full knowledge of these risks. I therefore forever waive, release and discharge the Town of West Hartford from any and all claims, losses, or liabilities for death, personal injury, partial or permanent disability, property damage, medical or hospital bills, or theft which may arise out of or related to my participation in this program.
       
    • I further agree to defend, indemnify and save the Town of West Hartford, their officers, employees and agents harmless from any and all claims, costs and damages resulting from injury to any person or damage to property, of whatsoever nature arising out of or incident to the CERT program.

    I have carefully read this agreement and understand that this is a contract between myself and the Town of West Hartford. My signature indicates that I have read this release in its entirety, understand all of its terms and have had any questions regarding this release, or its effect, satisfactorily answered.

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