Community Disaster Planning Coalition (CDPC) Learning Center
County Team Application Guidance
Enrollment Policies / Eligibility
Enrollment in the program is very selective and limited to one team per Florida county. It is recommended that each
county team be comprised of 6 members per team. There must be at least one member from each team who represents
public health, at least one member from each team who represents emergency management, and at least one member
from each team who represents human services. All team members must meet the selection criteria and learner prerequisites specified for the CDPC Learning Center program. Participants may not participate in this program more than
once and counties may not participate more than one time.
Application Timeline
Participation is limited and the program fills fast, so it is important for your county team to apply early. County team
applications are selected based upon: 1. the date that your completed county team application was submitted, and 2. the
meeting of all required application criteria. Note, priority will be given to County Team Applications that meet the
recommended selection criteria, are submitted by the stated application deadline, and are complete.
Application Procedures
Please carefully follow the instructions below to apply for the CDPC Learning Center program.
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CDPC Learning Center Program Application Checklist.
Download and complete the CDPC Learning Center County Team Application .
Note, please fill out all blanks on the County Team Application form completely or it will be rejected
and returned. The County Team Application must be coordinated, reviewed, and approved by the Health
Department Director or his/her designee in your respective county prior to your submitting it.
Each team member should download and complete the CDPC Individual Team Member Application.
Individual Team Member Applications must be submitted with your County Team Application.
Send completed application(s) to:
Sarasota County Health Department
2200 Ringling Blvd.
Sarasota, FL 34237-6102
Attn: Carol Jeffers, CDPC Learning Center Program Coordinator, USF/SCHD PERLC
Address any application questions to:
Carol Jeffers, CDPC Learning Center Program Coordinator
E-mail: [email protected]
Phone: 941-861-2765
Note, priority will be given to County Team Applications that meet the recommended selection criteria, are
submitted by the stated application deadline, and are complete.
After Each Application Period
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University of South Florida (USF) and Sarasota County Health Department (SCHD) Preparedness and
Emergency Response Learning Center (PERLC) staff will review the CDPC Learning Center County Team
Applications and notify applicants regarding their status as noted above.
The USF PERLC will post any remaining vacancies on the USF PERLC CDPC website and interested counties
may continue to apply. USF PERLC will fill vacancies on a first-come, first-served basis.
Community Disaster Planning Coalition (CDPC) Learning Center
County Team Application Checklist
 Only one County Team Application is submitted per county.
 The county team is comprised of six team members: one representing public health, one from emergency
management, and one from human services. (Note, one team member must be from public health, one team
member must be from emergency management, and one team member must be from human services; one
alternate team member must be designated from each of the three sectors for a total of three alternate team
members.)
 All individual team members completed the Individual Application and meet all stated CDPC Learning Center
criteria.
 The County Team Application is complete and meets the application criteria.
 The County Team Application is signed by County Health Department Director or Designee.
 Six Individual Team Member Applications and three alternate Individual Team Member Applications are
complete and enclosed with the County Team Application.
 The County Team Application is submitted by the application deadline.
Community Disaster Planning Coalition (CDPC) Learning Center
County Team Application
1. County Name (Note, only one application per county):
2. Training Dates Requested
Date #1:
Date #2:
Date #3:
(Please give choices by priority)
Section 1: General County Team Liaison Contact Information
3. Team Liaison Name (Last, First, Middle Initial, Suffix):
4. Business Address (Street, City, State, Zip Code):
5. Work Phone No.: (
)
6. Fax No.: (
)
7. E-Mail Address:
Section 2: General County Team Member Information
8. Names of All Team Members: (Identify 6 team members + 3 alternate members)
Note: Attach all completed Individual Team Member Applications and submit with this application.
Member #1 (Public Health):
Member #2 (Emergency
Member #3 (Human Services):
Mgmt):
Member #4:
Member #5:
Member #6:
Alternate #1 (Public Health):
Alternate #2 (Emergency
Alternate #3 (Human Services):
Mgmt):
9. Does your team include at least one member and one alternate member from each of the three sectors:
public health, emergency management, and human services? (Circle)
Yes
No
If “no”, provide explanation:
List organizations represented by the team members:
1.
4.
2.
5.
3.
6.
7.
8.
9.
10. Do all team members meet or exceed the stated learner pre-requisites? (Circle)
Yes
No
11. Have all team members received prior authorization to travel? (Circle)
Yes
No
12. Have all team members received authorization to participate in training? (Circle)
Yes
No
13. Are all team member individual applications attached? (Circle)
Yes
No
14. a. Does your county/community have an active COAD and/or VOAD? (Circle)
Yes
No
14. b. If “yes”, are any of those members participating in the training? (Circle)
Yes
No
14. c. If ”no”, why not? Please describe.
Section 3: Endorsement and Approval
15. I certify that this application is complete and that the information recorded in this application is correct.
16. a. Team Liaison’s Signature:
16. b. Date:
17. I endorse the team members identified on this application as representatives from my county and
approve their participation in the CDPC Learning Center program. (County Health Department Director)
18.a. County Health Department Director’s Signature:
18.b. Printed Name:
19. Submit completed application to:
Sarasota County Health Department
2200 Ringling Blvd.
Sarasota, FL 34237-6102
Attn: Carol Jeffers, CDPC Program Coordinator, USF/SCHD PERLC
Section 4: CDPC Learning Center Reviewer Information (For internal use only)
20. Date Application received by CDPC Staff:
21. Is application complete? (Circle)
Yes
No
22. Application Disposition: (Circle)
Accepted
Declined (Reason)
23. a. Application Reviewer’s Name:
24. Date Application Reviewed:
23.b. Signature of Reviewer:
25. Date Team Liaison Notified:
Community Disaster Planning Coalition (CDPC) Learning Center
Individual Team Member Application
Section 1: General County Team Member Information
1. Team Member Name (Last, First, Middle Initial, Suffix):
2. Agency/Organization Name:
3. Position Title:
4. Business Address (Street, City, State, Zip Code):
5. County:
6. Work Phone No.: (
)
7. Fax No.: (
)
8. E-Mail Address:
9. Check the box that best describes your agency/organization:
 County health department
 County/Municipal government
 Public safety/emergency management
 Local American Red Cross chapter
 School system
 Faith-based organization
 Not-for-profit organization
 Private business
 Hospital/Health care organization
 Other: ______________________
10. Do you meet or exceed the stated learner pre-requisites below? (Circle)
If no, please explain:
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Yes
No
Learner Pre-Requisite Knowledge, Skill, Abilities: (Check each box that applies)
 Leadership/supervisory skills and role in my agency or organization
 Successful completion of ICS 100, 200, 700, 800 (FEMA online courses)
 Knowledge of my agency’s/organization’s role in the community
 Experience in collaborating/building community partnerships with other agencies/organizations
 Active role in my community’s disaster response team
 Interest in actively participating in community disaster response
11. Have you received prior authorization to travel? (Circle)
Yes
No
12. Have you received authorization to participate in this training? (Circle)
Yes
No
13. Have you signed and attached the training commitment letter? (Circle)
Yes
No
14. Do you have any disabilities (including allergies or dietary restrictions) which would require special
assistance or accommodation during your attendance in training? (Circle)
Yes
No
14.b. If “yes”, describe and indicate any special assistance or accommodation required.
Section 2: Endorsement and Approval
15. I certify that this application is complete and that the information recorded in this application is correct.
16. a. Team Member’s Signature:
16. b. Date:
17. I endorse the team members identified on this application as representatives from my
agency/organization and approve their participation in the CDPC Learning Center program.
(Supervisor/Director)
18.a. Team Member Supervisor/Director’s Signature:
18.b. Printed Name:
19. Submit completed application to:
Sarasota County Health Department
2200 Ringling Blvd.
Sarasota, FL 34237-6102
Attn: Carol Jeffers, CDPC Program Coordinator, USF/SCHD PERLC
Section 3: CDPC Learning Center Reviewer Information (For internal use only)
20. Date Application received by CDPC Staff:
21. Is application complete? (Circle)
Yes
No
22. Application Disposition: (Circle)
Accepted
Declined (Reason)
23. a. Application Reviewer’s Name:
24. Date Application Reviewed:
23.b. Signature of Reviewer:
25. Date Team Liaison Notified:
CDPC Learning Center
Individual Team Member Commitment Pledge
Individual Team Member Participation Requirements:
The benefits to your personal and professional development, as well as to the agency and county you
represent, are directly related to your intellectual engagement on an individual and collaborative basis. As a
participant of the CDPC Learning Center, you are expected to:
 Be intentional as it relates to your professional development.
 Take ownership of, and actively participate in, this two-year learning experience by putting forth
the required effort to make it a success.
 Agree to be held accountable by your fellow county team members for your continued
engagement and contributions to the process.
 Commit to supporting your county team members in meeting the CDPC Learning Center
expectations.
 Work within your county team to apply the practices and principles you learn in the CDPC
Learning Center.
 Share your results and lessons learned with other county CDPC members.
The above will require you to delve into, read, and become intellectually engaged with the learning
materials provided throughout the duration of the two-year CDPC Learning Center program. In short, you
must be a dedicated and active learner in spirit and in practice.
Pledge of Active Learning Center Participation:
I understand that the investment my agency and county are making in me is designed for the overall
betterment of the operational effectiveness of my own agency, as well as the county. Therefore, I pledge to
make the most of this learning experience and use the knowledge gained toward that end.
CDPC Learning Center cohort members pledge to:
 Complete any pre-work prior to attending the on-site training sessions.
 Prepare for on-site and distance learning sessions—read, study, and gather required data and
information.
 Participate in on-site group training—contribute to discussions and the sharing of experiences.
 Participate in distance learning training with other members of my county team.
 Apply and implement new knowledge into practice in my county—through reflection and direct
action.
Commitment Statement:
I understand the purpose of the CDPC Learning Center program and will devote the time and resources
necessary to complete the two-year CDPC Learning Center program. I understand that even though
emergencies do arise, I have an obligation to my fellow county team members to uphold my pledge of
participation to the best of my ability.
I have the full support of my supervisor for the time required to participate in the training and in
implementing the recommendations that result from this learning experience. I understand that the learning
extends beyond the days of planned training meetings during two consecutive calendar years.
By signing below, I acknowledge that I understand and will uphold this commitment.
_______________________________________________________
Signature
____________________
Date