1 Start 2 Complete CERT Training Registration Form BASIC COURSE Community Emergency Response Team (C.E.R.T.) Basic Course Registration First Name * Last Name * Birth Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20172018201920202021 Year Address * City * State * Zip Code * Cell Phone * E-mail Physical Limitations (Describe special accommodations needed if any) Other Volunteer Organizations if any Felony Convictions * Yes No Which class are you registering for? * Submit
