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 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. *
