Charles County Emergency Services VOLUNTEER REGISTRATION FORM. Last Name: First Name: Middle Initial:

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1 Charles County Emergency Services VOLUNTEER REGISTRATION FORM Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Home Number: Work Number: Pager Number: Cell Number: Neighborhood or Community: Address: Do you have a disability or require special accommodations? If yes, list special accommodations needs: Age Group: Emergency Information: In case of emergency, person to contact should be: Name: Relationship: Address: City: State: Zip Code: Phone Number: I declare under penalty of perjury that all statements on this enrollment form and attachments are true and complete to the best of my knowledge. I understand that false, misleading, or incomplete information shall be cause for disqualification. Volunteer Signature: If under 18 years of age must have Parent or Guardian consent: Parent/Guardian signature of consent: Date 1

2 Driver s license/id #: Background Information: State Issued: License Expiration License Classification (A,B,C): Have you ever been convicted of a crime other than minor traffic violations: Yes No Do you have any previous, current, or pending legal, penal, or parole restrictions that now limit or may limit your future access to people, public or private areas? Any outstanding warrants? Are you listed on a public website as a former offender? Please explain: CERT Information How did you learn about Charles County CERT? After you graduate from CERT, we want you to stay active in your local CERT team and with Charles County CERT to organize a local team, plan for disasters, work at special events, recruit other volunteers, etc. What level of volunteer participation will you offer after completion of your CERT training: Are there any certain skills, licenses, training or knowledge you wish to utilize with CERT? Are you willing to help (build or join) a CERT team in your neighborhood? Yes No Are you willing to help CERT teams in other areas? Yes No What is your availability for CERT activities? 2

3 By signing below, you agree to these terms: I certify that these statements are true and I have not made omissions. I authorize investigation of all statements contained in this application and understand that a background check may be conducted and there may be safety restrictions for participation; I authorize the Charles County Department of Emergency Services, its partners, agents, employees and assignees to secure information about me and release all of these and associated parties from any liability arising from such investigation or my CERT participation; I agree to notify the Charles County CERT program if I am charged or convicted of a crime in the future with the understanding that certain convictions may preclude me from continued service. I grant the Charles County Emergency Services and its designees an unlimited model release and a photography release to allow them to use my name, image, photos, video and/or stories featuring me or as shot by me, to be used in any and all uses and media in perpetuity without payment for this use. Signature of Applicant: If under 18 years of age must have Parent or Guardian consent: Parent/Guardian Signature of Consent: Please complete and mail form to: Charles County Department of Emergency Services Attention: Jennifer Adams P.O. Box 2150 La Plata, Maryland (301)

4 Emergency Medical Care. (a) In general A person described in subsection (b) of this section is not civilly liable for any act or omission in giving any assistance or medical care, if: (1) The act or omission is not one of gross negligence; (2) The assistance or medical care is provided without fee or other compensation; and (3) The assistance or medical care is provided: (i) (ii) (iii) At the scene of an emergency; In transit to a medical facility; or Through communications with personnel providing emergency assistance. (b) Applicability - Subsection (a) of this section applies to the following: (1) An individual who is licensed by this State to provide medical care; (2) A member of any State, county, municipal, or volunteer fire department, ambulance and rescue squad or law enforcement agency or of the National Ski Patrol System, or a corporate fire department responding to a call outside of its corporate premises, if the member: (i) (ii) Has completed an American Red Cross course in advance first aid and has current card showing that status; Has completed an equivalent of an American Red Cross course in advanced first aid, as determined by the Secretary of Health and Mental Hygiene; or (3) A volunteer fire department, ambulance and rescue squad whose members have immunity; and (4) A corporation when its fire department personnel are immune under paragraph (2) of this subsection. (c) Immunity for individual not covered by this section An individual who is not covered otherwise by this section is not civilly liable for any act or omission in providing assistance or medical aid to a victim at the scene of an emergency, if: (1) The assistance or aid is provided in a reasonably prudent manner; (2) The assistance or aid is provided without fee or other compensation; and

5 (3) The individual relinquishes care of the victim when someone who is licensed or certified by this State to provide medical care or services becomes available to take responsibility. [1982, ch. 770, 4; ch. 775; 1983, ch. 248; 1997, ch. 14, 9; ch. 201, 2.] 9/11/2006

6 Charles County Emergency Services Community Emergency Response Team Program LEGAL STATUS OF CERT PARTICIPANTS During the CERT training itself and thereafter (when on a self-initiated basis, putting the training into practice during an emergency), participants are deemed to be volunteers and not employees or agents of the Charles County Government, Law Enforcement or Charles County Emergency Services. As such, volunteers are not entitled to any of the privileges, immunities or insurance coverage afforded employees of the Charles County Government. That is to say, volunteers are not covered by or under the County s Workers Compensation, Unemployment Compensation, liability coverage or hospital/medical plans. Volunteers, however, may have certain immunity from civil liability under the Maryland Good Samaritan Law, Maryland Code, Courts & Judicial Proceedings Article, Section

7 Charles County Emergency Services Community Emergency Response Team Program STATEMENT OF UNDERSTANDING I understand that by completing the Community Emergency Response Team course, I will be taught 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. I understand that I will receive a Certificate of Completion upon attending the nine modules of the course. I hereby acknowledge receipt of Legal Status of CERT Participants and have executed the Release, Hold Harmless and Indemnification Agreement. Signature: If under 18 years of age must have Parent or Guardian consent: Parent/Guardian Signature of Consent: Please complete and mail form to: Charles County Department of Emergency Services Attention: Jennifer Adams P.O. Box 2150 La Plata, Maryland (301)

8 Charles County Emergency Services Community Emergency Response Team Program RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT THIS RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT is voluntarily given and executed by (hereinafter referred to as Participant). In consideration of the Charles County Emergency Services providing Community Emergency Response Team (CERT) training, Participant hereby releases, agrees and promises to hold harmless and indemnify the Charles County Government and its officers, employees, agents or servants, from and against any and all liability, claims, demands, damages, fines, penalties, expenses, fees, suits, proceedings, actions and costs of actions, including reasonable attorney s fees for trial and/or appeal, of any kind or nature arising or growing out of or in any way connected, directly or indirectly, with any act or omission of the Charles County Government and its officers, employees, agents or servants, arising, or as a result of the CERT training as stated above. DATED this day of, 20. Participant Signature: Typed or Printed Name: If under 18 years of age must have Parent or Guardian consent: Parent/Guardian Signature of Consent: Witness Signature: WITNESS: Typed or Printed Name: Please complete and mail form to: Charles County Department of Emergency Services Attention: Jennifer Adams P.O. Box 2150 La Plata, Maryland (301)