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Today is Saturday, November 21, 2009.

CERT Community Emergency Response Team (Registration)

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Purpose. This form is used to submit an application to the Community Emergency Response Team Coordinator for the next class. Classes are held at the Fire/EMS building; 5888 McPicken Dr. Graduates of the program that live in Clermont County will receive a CERT backpack at no charge. Non Clermont County residents will be responsible for providing their own CERT backpacks for the class. A list of suggested items for the bag will be provided.

* Information is required.

Contact Information

* First Name:
* Last Name:
Business Name:
* Email:
* Daytime Phone:	() –
* Fax:	() –
* Address:
* City:
* State:
* ZIP:

* What county do you live in?

* Have you ever been arrested for an offense other than a traffic violation?

Yes

If you answered yes, please describe the offence

* Have you taken prior emergency response training?

If yes, briefly describe the course(s)

* I hereby authorize the Miami Township Police Department to conduct an investigation into any Traffic or Criminal convictions that I have. I understand that this Traffic and Criminal Background investigation is being conducted as part of Miami Township Community Emergency Response Team consideration of my application for participation in their Community Emergency Response Team training and that the results thereof will be utilized for purposes of determining my eligibility to participate in the Community Emergency Response Training. Do you agree?

Yes, please accept my application

No, please refuse my application

* Authorization to use Image and Photographic Likeness: In the event the participant or my photograph or other image is taken or created during the participant or my participation in this program, in consideration of the acceptance of the participant in the program, I authorize Miami Township to use my photograph or other image for any purpose. Do you agree?

Yes, please accept my application

No, please refuse my applicaton

Check here to have email confirmation of this request sent.

* Information is required.

Notes:

If you send us a message, you'll receive a Tracking Number allowing you to follow-up with your request, at your convenience.

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