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Rockdale County
Community Emergency Response Team
Volunteer Application

ROCKDALE COUNTY EMA

COMMUNITY EMERGENCY RESPONSE TEAM

Dear Applicant,
I would like to take this opportunity to thank you for your interest in the Community Emergency Response Team. The Community Emergency Response Team Volunteer Program (CERT Volunteer Program) is presented by the Rockdale County Emergency Management Agency (RCEMA). I thank you for your willingness to give up your valuable time to participate in the program. I hope that the classes will be a rewarding and informative educational experience.
This program was designed to provide citizens with basic information about what to do in the first hours of an emergency. The ultimate objective is to establish and maintain an active CERT Volunteer Program within our community through training and education
After completion of this program, I hope you will use the information to help educate both your friends, loved ones and families within your neighborhood concerning emergency response preparedness. Your application for admission to the CERT Volunteer Program demonstrates your commitment to your community.
You will be contacted before the class begins and we will make every effort to keep you informed throughout the process. If due to unforeseen circumstances, you are unable to attend, please notify the CERT Program Manager at 770-278-8407 or elizabeth.white@rockdale26.soliademo.com
Again, thank you for your interest in the Rockdale County EMA’s Community Emergency Response Team Volunteer Program.

Sharon Webb,
Director of Rockdale County EMA

PROGRAM IMPORTANT INFORMATION

Please Note the following: Please fill out the Application for Enrollment in its entirety. Class members must be at least 18 years of age at the start of the program and a resident of Georgia. All applicants will be subject to a criminal history background check as a precondition to acceptance into the program. You will be notified by email from the CERT Program Manager once your initial application has been submitted successfully to request additional information that may be required as part of the application process. The EMA Director has final approval of all applicants and reserves the right to deny entry to any applicant. Accepted applicants will be notified by email and/or phone. Class size is limited to the first qualified twenty applicants per class offering. Dress for class is casual attire (no shorts, halters, etc.) Name badges will be provided and should be worn during class. Qualified applicants who are denied admission due to class size will be given first choice at the time the next class is scheduled. Waiver of Liability forms must be signed and submitted by the applicant with the completed application prior to the class starting. Location and dates of classes will be sent to accepted applicants with sufficient prior notice. Please advise immediately of any conflicts. The Rockdale County EMA Department will make reasonable efforts to assure all persons have access to any programs and services. If a disability requires special accommodation, please contact Rockdale County EMA at (770) 278-8405.

Additionally, please contact Rockdale County EMA at 770-278-8405 for any additional information.

Click here to download PDF application

EMA - CERT Volunteer Application

Date

Applicant Information

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Preferred Contact Number(Required)

Current Occupation(Required)

Email(Required)

Employer(s)(Required)

How long have you lived in Georgia? In Rockdale County?(Required)

How did you hear about this program?

Are you committed, willing, and able, to attend all scheduled classes?(Required)

Yes

No

Have you ever been arrested for any offense YES NO (other than minor traffic offenses)?(Required)

Yes

No

If yes, please explain and provide date and location.

Do you have any food allergies, dietary restrictions or environmental factors?(Required)

Yes

No

If yes, please list

Shirt size (Men's):

Shirt size (Women’s)

Background

Please list any relevant special skills or training:

Disclaimer and Signature

Consent(Required)

Please check to acknowledge

I hereby certify that the information contained in this application is true and correct to the best of my knowledge. Rockdale County EMA is authorized to conduct any investigation of my personal history information that is deemed necessary for consideration to participate or continued participation in the Community Emergency Response Team Program.

Signature(Required)

Date(Required)

For Official Use Only:
Date/Time Received:
Criminal History:
Check Date/Time:
Director Approval:

WAIVER OF LIABILITY

Whereas I,

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Perfered Number(Required)

Have made a voluntary request on my own initiative to participate in the Community Emergency Response Team with the Rockdale County EMA Department, Conyers, Georgia.
Now, therefore in consideration of the County of Rockdale County allowing me to participate in the Community Emergency Response Team program and in consideration of the County of Rockdale County and the Rockdale County EMA permitting me the use of its facilities, the validity, sufficiency, and receipt of which consideration is acknowledged, I do hereby, for myself, my heirs, executors, and administrators, remise, release and forever discharge the County of Rockdale County and the Rockdale County EMA, its employees, officers, commissioned staff, representatives, instructors, Board of Directors, Training Committee Members, affiliates, and agents, acting officially or otherwise (hereinafter referred to as Rockdale County) from any and all claims, actions, demands, or causes of action, on account of my death or on account of my personal injury or damage to my personal property which may occur, regardless of whether or not said harm or injury occurs through the negligence, misfeasance, or malfeasance on the part of Rockdale County, or whether said harm or damage occurs through acts of a person not employed by Rockdale County.

Consent(Required)

I ACKNOWLEDGE that I understand that CERT training will involve active physical participation, which includes a potential risk of personal injury and/or personal property damage, and that I make the request to participate in the program with full knowledge of these risks. I ASSUME THE RISK of all injuries that may occur because of my participation in the Community Emergency Response Team program.(Required)

Consent(Required)

I ACKNOWLEDGE that my participation in the Community Emergency Response Team program and any continued educational training is strictly voluntary and does not grant employment rights, employee benefits, or a vested/liberty interest as an employee with the County of Rockdale County.(Required)

Consent(Required)

I ACKNOWLEDGE that my participation in the Community Emergency Response Team and any continued disaster educational training, may cause me to view possibly graphic and/or hazardous emergency photographs or scenes, I ACKNOWLEDGE and AGREE to exercise reasonable care while participating in any of the Community Emergency Response Training program. I further acknowledge that I am solely responsible for any medical or other expenses resulting from accidents, injuries, or illnesses that I may incur or be exposed to because of my participation with the Community Emergency Response Team.(Required)

Consent(Required)

I AGREE to abide by all instructions given to me by the Rockdale County Fire-Rescue personnel, Rockdale County EMA, and other instructors and safety officers while participating in the Community Emergency Response Team(Required)

WAIVER OF LIABILITY

and I UNDERSTAND if I fail to follow the instructor’s rules/regulation, or if I fail to exercise reasonable care, I can be administratively removed from the program. While participating in any Community Emergency Response Team training, I may gain access to information or documents of a sensitive nature, and/or information deemed confidential by the Rockdale County EMA, the State of Georgia, or other entities. I agree that I will not release ANY information, items obtained by me, or sensitive materials that I may become privy to in the course of my participation in the program. While participating in the Community Emergency Response Team, I agree to advise the program coordinator, immediately, of any interaction I may have with any law enforcement official involving a criminal investigation against me or my arrest. I HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS Rockdale County from and against any and all liability, loss, cost or expense (including attorneys' fees) arising from or in any manner connected with being permitted to participate in the Community Emergency Response Team program. I HAVE READ AND UNDERSTAND THIS AGREEMENT AND BY SIGNING IT I VOLUNTARILY INTEND TO RELEASE AND INDEMNIFY, ROCKDALE COUNTY, GEORGIA FROM ANY AND ALL LIABILITY FOR PERSONAL INJURY OR PROPERTY DAMAGE THAT RESULTS FROM MY PARTICIPATION IN THE COMMUNITY EMERGENCY RESPONSE TEAM PROGRAM.

Signature(Required)

Date(Required)

Witness(Required)

THIS RELEASE MUST BE EXECUTED PRIOR TO PARTICIPATION IN THE COMMUNITY EMERGENCY RESPONSE TEAM PROGRAM. COMMUNITY EMERGENCY RESPONSE TEAM ROCKDALE COUNTY EMA STOCKBRIDGE, GEORGIA 30281

LIKENESS WAIVER

Release and Waiver of Liability: I am an adult over the age of 18 years (or the parent of a minor child). I authorize Rockdale County EMA and Rockdale County to use my name and display my image and likeness ( or the likeness of said minor child) on the EMA Department's website or media publications, brochures, broadcasts, telecasts or newspaper articles and social media. This authorization shall remain in effect until revoked by me in writing. By offering my signature below, I acknowledge acceptance of this waiver and agree to allow the use of my (or minor child's) likeness from any photos or video taken that specifically involve activities related to Rockdale County EMA’s Community Emergency Response Team. I understand that the photos or video could be used to advertise and/or promote the Rockdale County EMA Department's community relations activities.

Authorized Signature(Required)

Date(Required)

Printed Name(Required)

Witness (CERT Program Manager)

Submit