CERT Training Application

First Name

Last Name

Pronouns

Preferred name

Race/ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

If you live in Auburn, in what area

Email Address

Phone Number

Do you require interpretive services?

Yes

Please describe interpretive services needed

Do you require any accommodations?

Yes

Please describe accomodations needed

How did you hear about CERT?

Emergency Contact Name

Emergency Contact Number

Assumption of Risk/Exculpatory Clause: For and in consideration of the opportunity offered to me to participate in the above-named activity/activities offered by the City of Auburn Office of Emergency Management, I, as evidenced by my signature below, do hereby hold harmless, release, and waive all claims I may have against the City of Auburn, its officials, employees, agents, or contracted instructors, or any other person(s) involved in this activity for any and all injuries, losses, or damages suffered by myself as result of my participation in this activity/activities. I accept full responsibility for the cost of treatment for any injury, losses, damages, or death suffered by myself while taking part in this activity/activities. I give permission to have my photograph taken during classes and used for publicity purposes by the City of Auburn.

I Agree

Signature of Applicant (or Parent/Guardian if applicant is under 18 years old)

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.