If you answered yes to the above question, please indicate what, when and where was the disposition of the offense.

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSITUTE AN AUTOMATIC BAR. Eligibility for consideration will be based on the nature of the offense and the duties and responsibilities of the program for which you are applying. Omit convictions more than two years old for violations of Cal. Health & Safety Code Section 11357(b) or (a), 11360 (c), 11364, 11365 or 11550 as they relate to marijuana before January 1, 1976, and their statutory predecessors.

As a member of the Newport Beach Fire Department Community Emergency Response Team (CERT), you have the option of having your contact information included in the City of Newport Beach CERT Volunteer Directory. I understand this information is a public record and may be disclosed to members of the Newport Beach Fire Department and graduates of the Newport Beach CERT Volunteer Program for the purposes of forming CERT teams within my neighborhood.

1. I will dial 911 for all emergencies and ensure the safety of myself and my family before assisting my neighborhood and the City of Newport Beach CERT activation plan if and when I am deployed.
2. I will act professionally while participating in the CERT program and promise not to engage in any conduct which would reflect negatively on the CERT program or the City of Newport Beach.
3. I will not use the City of Newport Beach, Fire Department, or CERT’s insignias, emblems, logos, trademarks, or other identifying marks, equipment, property, uniforms, or any other evidence of membership or participation in in the CERT program for personal or private purposes, gain, notoriety, or to influence any city employee, police, fire official, or other person during a non-emergency situation.
4. I will act within the scope of my training, wearing appropriate personal safety equipment and/or uniform with identification, and will not take, use, smoke, or be under the influence of any alcohol or drugs that can impair physical or mental functioning while participating in CERT activities.
5. I will not have within my possession a knife, firearm, or any other similar weapon, with the exception of tools related to emergency response or assistance, while training or serving my duties and obligations under CERT.
6. I will not accept or seek, on behalf of myself or any other person, any money, gifts, or donations as a result of my affiliation with CERT.
7. I will follow all CERT program management and City official directions during any event, disaster or drill, except when compliance with orders would be criminal in nature or would endanger any person or property.
8. I will treat my fellow CERT members, City officials, City employees, the public, and disaster victims with respect and dignity. I understand wrongful discrimination or harassment is prohibited and will not be tolerated.
9. I will follow the CERT program rules, policies, and procedures.
10. I will respect the privacy of persons served by CERT and hold, in confidence, all sensitive, private, and personal information. I will not take any photos or videos while participating in CERT activities unless ordered by supervising CERT members in the chain of command and using a CERT photography device.
11. I certify that the information on this CERT application is true and correct.

I hereby apply for membership in the City of Newport Beach CERT program and authorize a law enforcement agency to perform a criminal background check.  I understand and agree that any misrepresentation in this document may result in immediate suspension or termination of my membership in the CERT program.

In consideration for the City of Newport Beach (“City”) allowing me to voluntarily participate in the Community Emergency Response Team (CERT) Program (“Program”), I hereby agree as follows:

1. Guidelines. I have read and agree to comply with the Program policies, rules, and regulations, and additionally, I agree to comply with other all applicable laws, rules, ordinances, regulations, policies, and procedures while volunteering.

2. Volunteer. I understand that if I am accepted into the Program I will be a volunteer, not an employee of the City, and that no civil service status, benefits, insurance, compensation, consideration, or other right of employment shall accrue, or be due, to me. 

3. Termination. I understand and agree that the City may terminate my participation in the Program at any time, with or without cause, in its sole and absolute discretion.

4. Background Check. I authorize the City to conduct a criminal background check upon my application into the Program, and periodically thereafter according to City policies and procedures.

5. Emergency Services Act. I recognize that if I am accepted into the program as a volunteer, I will be covered by the provisions of the California Emergency Services Act during the time that I am performing approved volunteer activities, and accordingly, workers compensation benefits shall be the exclusive remedy for any injury that I sustain in the course and scope of my approved participation in the Program.

6. Health Insurance. I certify that I have health insurance at the minimum coverage levels established by law which shall cover the cost of any emergency or other medical care that I may receive for an illness or injury that is outside of the coverage of the Emergency Services Act workers compensation coverage. To the extent that I do not have medical insurance coverage, I understand and agree that I will be solely responsible for any and all costs, fees, or other financial obligations.

7. Assumption of the Risk. I am aware that my participation could result in injury to myself or others, including but not limited to, bodily injury, personal injury, death, disability, illness, property damage, or loss (hereinafter, “Risk of Injury”). I acknowledge that my participation is voluntary, and do so with full knowledge of the Risk of Injury. To the extent authorized by law, I hereby accept responsibility for any and all Risk of Injury on behalf of myself, and my descendants, dependents, spouse, domestic partners, heirs, executors, administrators, devisees, representatives and assigns, and anyone who might claim on behalf thereof (hereinafter, “Releasors”).

8. Waiver and Release. To the extent authorized by law, on behalf of myself and Releasors I hereby release, discharge, and hold harmless the City, its officials, officers, agents, representatives, volunteers, employees, contractors, subcontractors, commissions, committees, foundations, and other such persons or bodies (hereinafter, “Released Parties”) from any and all liability for claims, demands, causes of action, damages, judgments, costs or expenses, compensation, consideration, remuneration, benefits, including but not limited to attorneys’ fees and costs (hereinafter, “Claims”), that are caused by, arise out of, in connection with, or result from my participation as a volunteer.

9. Unknown Claims. I understand that this release and waiver extends to all claims of every kind or nature whatsoever, either in law or in equity, foreseen or unforeseen, known or unknown, which arise or may hereafter arise from my participation as a volunteer, and that this release and waiver discharges the Released Parties from any Claims that I and the Releasors may have against the Released Parties. Further, on behalf of myself and Releasors, I hereby waive all rights under California Civil Code § 1542, which states:

A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the debtor or released party.

10. Name and Likeness. I hereby irrevocably grant worldwide rights to the City to copyright, publish, reproduce, exhibit, transmit, televise, digitize, display, and otherwise use and permit others to use my name, image, likeness and voice captured during the period of time that I am a volunteer, in any photographs, recordings, video, audio, writings or other publication in any form or medium whatsoever, including derivative works, now or hereafter created, for any purpose including, but not limited to, advertising, marketing, promotion, internet and social media, distributing to contractors, affiliates, or other third parties, or any other purpose whatsoever, without remuneration, compensation, royalties or other consideration to me, and I understand and agree that such material shall be the exclusive property of City to use in any manner in its sole and absolute discretion.

11. Defense and Indemnity. To the extent authorized by law, I hereby promise to defend and indemnify the Released Parties from any and all Claims, demands, obligations, damages, actions, suits, losses or liability that are caused by, arise out of, in connection with, or result from my participation as a volunteer, except to the extent of the sole negligence or willful misconduct of the Released Parties.

12. Medical Treatment. In the event of an emergency, I hereby authorize the Released Parties to make healthcare decisions and administer medical treatment to me if I am not capable of making healthcare decisions or administering medical treatment for myself until my power of attorney to make health care decisions for my behalf is able to do so.

 

I CERTIFY THAT I HAVE READ, UNDERSTOOD, AND VOLUNTARILY AGREE TO THE ABOVE, AND THAT MY CONSENT IS NOT BASED ON ANY PROMISES, CONDITIONS, STATEMENTS, REPRESENTATIONS, OR OTHER INDUCEMENTS NOT SET FORTH HEREIN.