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Application

NEW! Teen CERT Training! New program offered to students between the ages of 13-18. Download an application form and fax or mail it in.

Please complete your application by either downloading and filling out the PDF version here: CERT Application PDF, or by filling out and submitting your information through the form below.


 ACFormDisplay
* indicates a required field

Application

Personal Data
Last Name *

First Name *

Date of Birth
Select a date from the calendar.
Race

Gender

Height

Eye Color

Mailing Address

Home Telephone

Cellular Telephone

Work Phone

Pager

Fax Number

Primary E-Mail

Secondary E-Mail

Emergency Notification
Contact Name

Contact Telephone

Contact Address

Special Training
First Aid Training

Date of last First Aid Training

First Aid Training Authorizing Agency

CPR Training

Date of last CPR Training

CPR Training Authorizing Agency

Other Training

Languages Spoken Other Than English

Do you have any physical or medical conditions that might affect your participation in any exercise used in the course?

CERT Session Date Preference

CERT training is offered by Alachua County Fire Rescue (ACFR) at no charge to public. You will be given ACFR CERT Standard Operating Guide (SOG) and will be issued equipment by Alachua County Fire Rescue for use during activation and ACFR CERT sanctioned training. I understand that any and all equipment issued to me is the property of Alachua County Fire Rescue and that I am expected to return it in good condition upon demand or if I chose to resign from the ACFR CERT program.

I understand that that I will receive a "Certificate of Completion" only upon attending all modules of the course. In additionYouI will only become eligible to become an active ACFR CERT upon completion of IS-100 Introduction to Incident Command System and IS-700 National Incident Management System (NIMS). I will have seven weeks during the course to obtain IS 100 and IS 700 certificates from FEMA (http://training.fema.gov/IS/crslist.asp?page=1) via the internet and provide a copy to the instructor.

Active CERTS are required to attend regular scheduled CERT drills and or AFCR sanctioned CERT drills, training, conference etc. to maintain their Active CERT Status.

I understand that by completing this course I will learn certain basic skills that are intended to help me render assistance to others only 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.

By submitting this form, I affirm that I understand that when acting as a CERT volunteer I may only:

  1. Act within the scope of my official duties, and
  2. 2. Act in furtherance of a public purpose.

I understand that deviation from the above may result in personal liability.

Verification and Consent for Reference and Background Check

I verify that the above information is accurate to the best of my knowledge.

I give Alachua County Department of Public Safety permission to inquire into my educational background, references, licenses, police records, and employment and/or volunteer history. I also give permission to the holder of any such information to release it to Alachua County Department of Public Safety.

I hold Alachua County and Alachua County Department of Public Safety harmless of any liability, criminal or civil, that may arise as a result of the release of this information about me. I also hold harmless any individual or organization that provides information to the above-named agency. I understand that ACFR will use this information only as part of its verification of my volunteer application.



This website is a public service. Please read the Legal Disclaimer. Website designed and engineered by Alachua County ITS.Applications Division Version 2010 (v1.0)

Under Florida law (Statute 119.011), all information, including e-mail, written letters, documents and phone messages, sent to the Alachua County Board of County Commissioners is subject to Public Records law. This includes the sender's e-mail address, home address or phone number if shown in the message, the content of the message and any associated attachments to the mail. Also please be aware that electronic correspondence (e-mail) is made available on the Commission's public archive site immediately upon being sent. Instead, contact Alachua County Offices by phone or in writing.