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 Year1934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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
