REGISTRATION AND HOLD HARMLESS AGREEMENT

I would like to register for the CERT class that begins on:__________________________________, 2004.
                                                                                                                                               (Print month and date of first class session)

I am unable to attend the current session, please contact me about future courses.

NAME:___________________________________________________________________________________


E-MAIL:__________________________________________________________________________________

TITLE/OCCUPATION:_______________________________________________________________________

ADDRESS - Home or Work:__________________________________________________________________
                                   (Please circle one)
CITY:_______________________________   ZIP:____________________  FAX:_______________________

PHONE- HOME:_____________________ WORK:______________________CELL:____________________

I, the individual named above, hereby request permission to participate in the Fresno Community Emergency Response Team (CERT) program.  If I am under 18 parental approval is indicated by the signature below. 
I understand that training will involve active physical participation, which includes a potential risk of personal injury and/or personal property damage; and I make this request with full knowledge of these risks.  
Further, I have read and understand the program outline that describes all of the class sessions and associated activities (available at http://training.fema.gov/EMIWeb/CERT/).   
I agree to hold the City and County of Fresno, Fresno Citizen Corps Council and its directors, and their agents and personnel, harmless from any and all claims, actions, suits and/or injury that I may suffer which may arise as a result of my participation in the above mentioned program/class. 
 I agree to follow the rules established by the instructors, and to exercise reasonable care while participating in the CERT program.  I understand that if I fail to follow the instructor’s rules/regulations or if I fail to exercise reasonable care, 
I can be administratively removed from the program.   Additionally, I authorize the use of any photograph taken in connection with my participation in the program without compensation.  By executing this release, I certify that I have read this release in its entirety, understand all of its terms and have had any questions regarding the release or its effect satisfactorily answered.  I sign this release freely and voluntarily. 

Signature:_________________________________________________________ Date:___________________________

Signature of parent/guardian, if under 18:________________________________________________________________

Emergency Contact name/number:_____________________________________________________________________

Please return this form by mail, fax or email to:
Fresno Citizen Corps-CERT @ 2326 Fresno Street, Fresno CA  93721
FAX  (559) 488-1010; CitizenCorps@Fresno.gov


FOR OFFICE USE – Registration Confirmation Sent:________________________________ Via:______________________________________