CERT Emergency Preparedness

Doing the greatest good for the greatest number, together we can save a life, with training and preparedness.

CERT Class Enrollment Form

Community Emergency Response Team Volunteer Application 

For Cities of Antioch, Brentwood, Pittsburg, Oakley, Bay Point, Knightsen, Bethel Island, Discovery Bay  

 East County CERT Team 

 
Please answer all questions as completely as possible. All information will be treated confidentially. 
*Which City class
Brentwood
Pittsburg
Availability Volunteer Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning
Afternoon
Evenings
*CERT Training Requirements CERT Programs members will be required to complete the current class program curriculum
Yes
NO I do not agree
*CERT members may be required to complete additional training skills
Yes U agree
No I do not agree
*CERT members may be required to recertify every 5 years.
Yes I agree
No I do not agree
(sign at class swear in)


I verify that I am a resident of Contra Costa County and have been a California resident for a minimum of one year. 

I understand that a background check and fingerprinting will be required. [Initial here] 

I also verify that I have not been convicted of a felony or been convicted of a misdemeanor that resulted in imprisonment. 

If this information is incomplete or untrue I understand that my volunteer assignment can and will be terminated. 
CERT Program Representative_______________________________________________Date__________________  *Which class are you attending
Pittsburg
Brentwood  
Do you belong to:
Neighborhood Watch Group
Home Owners Association  Would your Church or Faith organization be interested in classes
none of the above
would they like to have training?
special training
Have you ever received training in:
First Aid  CPR  Emt
LPN  RN  Other Medical
Incident Command  Fire Suppression  Search & Rescue
Disaster Preparedness  Psychological First Aid  Hazardous Materials  Weather Emergencies
Damage Assessment  Communications  Law Enforcement  none of the above
Special training  
*My interest in this training is:
To learn Personal Emergency Preparedness
To learn Emergency Preparedness for my neighborhood
To be part of my City's Community Emergency Response Team
Time Available per week or events

Thank you for your request.    All information is confidential and used only for registration purposes.  Should you have any concerns or questions please note them in the comments box.