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Please complete this online form to the best of your ability, then click "submit" to email your application to the Balch Springs Fire Department.
*If you would like to complete a hard-copy of the application, please click here to download and print a PDF version of the application. Complete the form and submit to:
City of Balch SpringsAttn: CERT12500 Elam Rd.Balch Springs, TX 75180
Check all that apply
Note: A conviction of an offense will not necessarily eliminate you from consideration as a CERT member.
I hereby request permission to participate in the City of Balch Springs Community Emergency Response Team (CERT) program. I understand that participating in both this training and actual incidents as required involve active physical activity, which includes a potential risk of personal injury and/or personal property damage. I make this request with the full knowledge of the possibility of personal injury and/or personal property damage.
1. I agree to hold the City of Balch Springs, their personnel and their agents and all elected, appointed and volunteer employees 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 CERT program.
2. I attest that I am in good health, and have no medical or physical limitations or other circumstances that would prohibit me from executing the duties of a CERT member. If I do have limitations, I have disclosed these to the CERT Training Coordinator.
3. I agree to follow the program 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. In addition to the rules set forth by the CERT program, I also agree to conform to all rules and regulations of the City of Balch Springs. I understand that I will begin service on a reciprocal trial basis.
4. I agree to participate in all required training. I understand that I will perform services and assistance only to the degree that has been covered through my training. I will not perform services or assistance beyond the extent of which I have received proper training.
5. I understand that a background investigation and driver’s record review will be conducted, and that references may be requested and/or contacted. I will provide a list of references upon request by the City and authorize the City to contact any references provided. A successful background check/clearance is a prerequisite for program participation.
6. I understand my volunteer service represents an important commitment and realize the City is depending on my services. If, for any reason I cannot keep this commitment, I will notify my CERT supervisor in advance as required by this program.
7. I agree and understand that any work I perform within the scope of this agreement will be provided on a voluntary basis and that I do not expect nor will accept payment or any compensation for performing any work. I also understand that a volunteer position does not constitute any employee – employer relationship with the City of Balch Springs, and that I serve as the discretion of the City Manager or designee (Fire Chief).
8. If I am currently a City employee, I know that any volunteer work to be performed is outside of my regular job classification, and is separate from any paid work responsibility/compensation.
9. I agree not to divulge any information regarding persons who are receiving services or other assistance from the City or otherwise involved in my volunteer services. I recognize that unauthorized release of confidential information may subject me to legal action.
10. I understand that I am fully responsible for maintaining my own personal records of time volunteered to the City for the purposes of internships, community service, certifications, etc., and is subject to my CERT supervisor's verification. At the end of my volunteer service, I can request a letter documenting hours donated, and I understand that the City will maintain no permanent record of this time.
11. I understand that I am may not be covered under the City of Balch Springs’s Workers' Compensation insurance in the event of an injury from rendering a volunteer service. I understand that as a volunteer, I do have limited coverage for bodily injury through the City’s liability carrier when acting within the scope of my official duties as a City of Balch Springs CERT member. I agree to report any volunteer related injury or incident to my CERT supervisor immediately.
12. I understand the City has a zero-tolerance policy against any type of harassment or discrimination, and agree to comply with this policy.
13. I understand that the City has a zero-tolerance policy against any type of violence, threat or intimidation, implied or actual, in the workplace, and agree to comply with this policy.
14. I understand that the City has a zero-tolerance policy against any use of, or being under the influence of, illegal drugs or alcohol in the workplace and/or while performing my duties, and agree to comply with this policy.
15. I understand that the City has a zero-tolerance policy against carrying, or use of any type of weapon or firearm by individuals other than active members of the City of Balch Springs Police Department and its Police reserves while executing the duties of a CERT member, and agree to comply with this policy.
16. I understand that the City is not responsible for loss or damage to personal belongings or personal vehicles.
17. I understand that if I am under the age of eighteen (18) years, my parent or legal guardian will also register and participate in this class, and will personally supervise my participation in all future CERT activities (until I reach the age of eighteen (18).
18. I understand that I am responsible for the reasonable care and maintenance of any CERT related equipment issued to me by the City to and ensure its proper working order. This includes, but is not limited to, regular replacement batteries in equipment. I understand that the issued equipment/gear is owned by the City of Balch Springs, and will be returned to the City should my status as a CERT member terminate or upon the request of the Fire Chief. I understand that I am responsible for replacement costs of the equipment/gear if I terminate and fail to return the issued equipment/gear. 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 also certify that I have disclosed any and all known medical and physical limitations fully. I sign this release freely and voluntarily.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
I understand that in connection with my application for participation in the City of Balch Springs Community Emergency Response Team (CERT) the City will research and verify information that I have provided. I hereby authorize the City and/or entity directed by the City prior to or at any time after my acceptance into the CERT program to perform a background investigation. I understand this report may include inquiries regarding my work history, court records, including criminal convictions record as permitted by law, driving history and references supplied/obtained from professional and personal associates. I hereby authorize employers, educational institutions, consumer reporting agencies and other persons or entities having information about me to provide such information to the City of Balch Springs or other entities that obtain information for the City. I further fully release the City and hold harmless, its employees, officers, directors, agents, successors, and assignees and all other parties involved in the backgrounds / reference investigations. I understand results of my background / reference investigation check may be used in determining whether to accept / reject the application for participation in the CERT program. I accept that the Disclosure Authorization is not an offer for employment by the City of Balch Springs or a contract with the City. I further understand that no representative of the City of Balch Springs, CERT representative, instructor or other participant in the CERT program has the authority to enter into any agreement for employment for any specified period of time. All participants of the CERT program are considered at-will volunteers and can be dismissed from the program at any time for any reason.
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