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 Year1933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 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 If you have questions or need help with this form, please email [email protected] or call 951-320-8112. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
