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CERT Training Registration Form

Please correct the field(s) marked in red below:

Friday-Sunday, April 17-19 , 8 a.m. to 5 p.m.

Course takes place over three days. Please plan to attend every session.

A non-refundable fee of $40 is due prior to the start of class. Payment details will be provided after you register. 

1
Full Name
 *
2
Email Address
3
Phone Number
4
City
5
Zip Code
6
Participant Age
7
 Do you have any medical conditions that would prevent you from moderate physical activities?
Do you have any medical conditions that would prevent you from moderate physical activities?
8

Please describe any medical conditions that might impact your involvement:

Emergency Contact Information

9
Emergency Contact Name
10
Emergency Contact Phone
11
Emergency Contact Relationship to Participant

Participant Agreement

Risks, rules, photo release

12
Please review and accept the following conditions of participation:
 *
Please review and accept the following conditions of participation:
13
I certify that all statements set forth on my application are true and complete.
14

Additional Information

How did you hear about this class? What makes you interested in disaster response training?

15
I wish to learn more about volunteering with South County Fire
I wish to learn more about volunteering with South County Fire
16
Any comments or questions?
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