CERT Program Class Interest Registration

This is only an interest submittal. Completion of this form does not constitute enrollment for any class or session. You will be contacted for confirmation of enrollment prior to class.

Notes:

  • Each class is limited to 40 students.
  • Minimum age is 18 years old
Please complete all information marked with a (*)
Name: (*)
Address: (*)
City, State, ZIP: (*)
Phone (Home): XXX XXX-XXXX (*)
Phone (Work): XXX XXX-XXXX (*)
Cell Phone: XXX XXX-XXXX
Pager: XXX XXX-XXXX
E-Mail Address: (*)
1st Interest:
2nd Interest:
Do you have any special needs*?
* Such as vision or hearing loss, or a mobility limitation.

If Yes, please describe:
     

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