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 Year1935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 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
