May 2019 CERT Registration Form
This is the registration form for the CERT course hosted at Dartmouth-Hitchcock, Nashua. The course is one full weekend in May - Friday, May 3, 2019, 6-9pm; Saturday, May 4, 2019, 8am-5pm; and Sunday, May 5, 2019, 8am-5pm. If you need to cancel your registration in the class, please contact the Greater Nashua Public Health Network at 603.589.4569 or by email at cert@readynashua.org.
Email address *
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First Name *
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Last Name *
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Address *
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Town/City *
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State *
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Zip Code *
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Phone *
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Would you like a printed copy of the student manual? (Please note, it is also available electronically.) *
How did you find out about us?
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Please list any accommodations you may need for the class.
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I hereby request permission to participate in the Community Emergency Response Team Program. I understand that this training will involve active physical participation, which includes a potential risk of personal injury and/or personal property damage. I make this request with full knowledge of the possibility of personal injury and/or personal property damage. Further, I have read and understand the program outline that describes all class sections and the associated activities. I agree to hold the City of Nashua, and their agents and personnel, harmless from any and all claims, actions, suits, and/or injury that I may suffer and which may arise as a result of my participation in the above mentioned 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 and regulations or if I fail to exercise reasonable care, I can be administratively removed from the program. I hereby give my consent, in the case of injury or illness, to have a medical doctor, nurse, hospital, clinic, or other medical practitioner provide me with medical assistance and/ or treatment, and agree to be responsible financially for the reasonable cost of such assistance and/or treatment. I also consent, in the case of injury or illness, to first aid treatment. Informed Consent for Release of Information: By checking below, I grant permission for Office of Emergency Management, the Division of Public Health and Community Services, the City of Nashua, and its affiliates to use my name; any photos, film, or videos of me or my likeness; and/or any other identifying information about me, in legitimate accounts of my work and experience as a Community Emergency Response Team participant. 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. *
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A copy of your responses will be emailed to the address you provided.
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