City of Chicago
Community Emergency Response Team Volunteer Application

Community Emergency Response Team Volunteer Application

Background
 Do you have any physical limitations?
 
Due to the nature of work related to emergency management, the City performs a complete background check for volunteers.
By signing this application and initialing this section, I am providing the City of Chicago consent to conduct a fingerprint based criminal background check. I understand that my ability to participate as a CERT volunteer is contingent upon on this form is truthful. I understand that if I have provided any false or misrepresented information, I will be barred from participation as a CERT volunteer.
 
Demographic Information (optional): The City gathers statistical information to provide funding agents if necessary.
 
 Are you currently working or volunteering with a disaster relief agency or emergency response team?
 Are you available at any time/any day of the week?
Skills - Please check all of the below that apply to you
 
Languages (Fluent)
 Sign Language
(You have 2000 characters remaining)
(You have 2000 characters remaining)
 
Waivers, Releases and Agreements
By signing this form and initialing in the sections indicated, I certify that I have read the following sections and understand all terms and conditions:
Injury Waiver:
I do hereby state that my attendance and participation in the CERT program is voluntary. I assume all risks of injury to my person and property that may be sustained in connection with any activity related to the program. I do hereby release,waive and discharge the City ofChicago and any of its authorized agents, representatives, instructors or officials fromany claims, demands and actions and causes of action for any injury sustained to my person and/or property during my participation in the program or due to negligence or any other fault. I am aware that program components may include physical activities such as lifting, kneeling, bending, standing up or lying down. If I am not capable of performing such activities because of any physical limitations, I certify that I have informed the appropriate City of Chicago officials or representatives of those limitations and my inability to participate in those activities. If at any time, I feel that I cannot participate in an exercise due to any physical limitation, I will notify the appropriate City of Chicago officials or representatives immediately. I further agree to follow safety precautions at all times. I have read this section and fully understand its terms andconditions.
Photo and Video Waiver:
I understand that events in which I participate as a CERT volunteer may be photographed and/or videotaped for purposes of assessment, evaluation, outreach and public education. Images ofmyface and/or body, and/or the sound of my voice may be captured and I hereby consent to being photographed, audio taped and/or videotaped by authorized officials or representatives of the City of Chicago. I understand that the City of Chicago will not provide compensation of any kind to me in exchange for appearing in any video, audio or photographic medium. All rights to any image or sound related to my participation as a CERT volunteer will remain exclusively with the City of Chicago and the City of Chicago will retain the right to utilize those images and sounds in an appropriatemanner. The City of Chicago will retain complete discretion concerning the content and format of each photograph, video or audio tape and any program that is produced from a compilation or integration of such media. I waive any and all claims I may have now, or in the future, against the City of Chicago, its employees, agents or authorized representatives for capturing my voice or image and release them from any liability for any use of my voice or image.
Property Agreement:
Any and all equipment or materials provided to me during my participation as a CERT volunteer are and remain the property of the City of Chicago. If volunteer services are terminated by the City of Chicago or by my request, all equipment will be returned to the City of Chicago.
Release and Informed Consent:
I agree to be a volunteer to assist the City of Chicago in an emergency, disaster response and/or preparedness exercise. I will participate to the best of my ability in any required training or related event. I understand that my participation is strictly voluntary and I will not be compensated for my participation in any way. I understand that my participation may include providing my, own transportation to and from various locations as authorized by the City of Chicago and may involve physicalactivity.
I agree to hold harmless and release the City of Chicago and any of their departments, directors, officials, officers, employees, staff, agents, volunteers or other authorized representatives from any and all demands, actions, losses, damages, expenses, liability and claims by me, my family, estate, heirs or assigns for any damage, injury, illness, attorney's fees or harm from or in any way connected with any activities associated with my participation as a CERT volunteer.
As a CERT volunteer, I agree that I will conduct myself in an appropriate manner and as a City of Chicago employee. Acts of misconduct will be determined by the City of Chicago through its authorized Departments. Acts of misconduct may result in dismissal from any activity or event. The City of Chicago reserves the right to discharge any volunteer from active status.
I am signing this document freely and voluntarily. By signing this document, I certify that I have read and understand each part contained herein.
 
 

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City Hall, 121 North Lasalle Street
Chicago, IL 60602-1284

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