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Sanibel Fire and Rescue District - Sanibel
Police Department |
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2351 Palm Ridge Road |
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Sanibel, Florida 33957 |
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239-472-5525 |
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Community Emergency Response Team Training |
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Course Application |
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By completing this application in its
entirety, you will help the instruction team understand the general
profile of the class they are teaching. It is our promise that all
information will be kept confidential. |
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Submitting an application does not
guarantee admittance to the next scheduled class, but it does assure
that your interest is recorded and you will be notified of the next
class offering. |
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| Name______________________________________________________
SS#______________________________________ |
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First
M
Last |
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| Street
Address________________________________________________________________________________________ |
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| Neighborhood/Subdivision______________________________________________________________________________ |
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| Mailing Address (if different from above)_____________________________________________________________________ |
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| Occupation___________________________________________________________________________________________ |
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I understand that by completing this
course I will learn certain skills that are intended to help me render
assistance to others when I deem it safe and necessary for me to do so.
I am under no obligation, by virtue of having received this training, to
render aid or become involved in any activities that would make me feel
uncomfortable or have the potential to cause me physical or emotional
injury. |
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I recognize the fact that I will receive
a "Certificate of Completion", only upon attending all modules of the
course. I understand that there may be a minimal cost for the
course, providing me with the following items; CERT identification card,
CERT emergency bag and CERT t-shirt. |
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| __________________________________________
____________________________________________________ |
| Signature
Printed Name |
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| _____________________________ |
| Date |
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Home Phone______________________________
Work Phone__________________________________________ |
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| Cellular Phone________________________________
Pager____________________________________________ |
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| Do you own or have access to a (circle one): computer
(internet) or fax machine |
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| Internet Capability: E-mail
address________________________________________________________________________ |
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| Fax Machine: Fax
Number____________________________________________ Home
Office
Other |
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Do you have any physical or
medical conditions that might affect your participation in some of the
exercises used in the course? Such as, but not limited to: back
problems, heart condition, etc. |
| Please
Explain:________________________________________________________________________________________ |
| _____________________________________________________________________________________________________ |
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(Answering the above question by no means
disqualifies you from participating in this program, but it does allow
the instructors to consider limitations you may have in performing
certain tasks. All information will be kept confidential) |
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| Since we are a government agency, we require knowledge of any
criminal background |
| Have you ever committed a felony:
Yes_____ No_____ |
| If yes, please
explain:___________________________________________________________________________________ |
| _____________________________________________________________________________________________________ |
| _____________________________________________________________________________________________________ |
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(Answering the above question by no means
disqualifies you from participating in this program. All
information will be kept confidential.) |
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| What allergies do you
have:______________________________________________________________________________ |
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| How long have you lived in
Florida:_______________________________________________________________________ |
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| Do you reside on Sanibel
seasonally:______________________________________________________________________ |
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| Have you ever experienced a
hurricane:____________________________________________________________________ |
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| Briefly express your desired expectations from this
course:___________________________________________________ |
| _____________________________________________________________________________________________________ |
| _____________________________________________________________________________________________________ |
| _____________________________________________________________________________________________________ |
Do you consider yourself a leader? |
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| NO _______________Somewhat _________________Generally
________________Almost Always ________________ |
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| Have you ever . . . . . |
| served in the military or other agencies that you feel may help
you in this program? |
| Explain:______________________________________________________________________________________________ |
| _____________________________________________________________________________________________________ |
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| Have you received any of the following training? (circle all
that apply) |
| First Aid
CPR
EMT
LPN
RN
MD |
| Incident Command
Fire Suppression
Law Enforcement
Hazardous Materials |
| Communication
Search and Rescue Techniques
Disaster Preparedness |
| Weather Emergencies
Wilderness Survival
Damage Assessment
Documentation |
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This information will be kept in a
confidential file with the CERT coordinator. This information will
not be made public. |
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