Teen CERT Program

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Office of Emergency Services

Andrew Bogar

Emergency Manager

Emily Mazzone-Clementi

Outreach Coordinator

Teen CERT Registration

Please fill out the form below-

YOUTH CERT

Student's First Name:

Student's Last Name

Student's Telephone Number

Student's Email Address

Parent/Guardian's First Name:

Parent/Guardian's Last Name

Parent/Guardian's Telephone Number

Parent/Guardian's Email Address

Image Release

Blue Lake Rancheria (BLR) staff and/or BLR partners may take photographs or video at the event. This release form authorizes Blue Lake Rancheria Tribe the use of your name, city, and photo for electronic and print media advertising and promotional material. Any and all other information will be kept confidential. I hereby expressly grant Blue Lake Rancheria and its employees, agents and assignees the right to photograph me and the use of my picture, silhouette and other reproductions of my physical likeness (as the same may appear in any still camera photography, social media, video and/or motion picture film/commercial), in and in connection with the exhibition theatrically, on television, or otherwise, of any motion pictures in which the same may be used or incorporated, and/also in the advertising/publicizing of any such motion picture/product, not limited to television, print reproduction or motion pictures. I further give my consent to said company the right to reproduce in any manner whatsoever any recordings made by said company of my voice and all instrumental, musical or other sound effects produced by me. I enter into this agreement willingly and expect no compensation, either monetary or through gift of physical items and/or services.

Date / Time

By checking this box I understand that my photograph could be used for social media and advertising purposes.