CERT Course Registration Form

SANTAQUIN CITY

CERT Registration Form
Today's Date*

MonthDayYear
Date mm-dd-yyyy
Student Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
Verify E-mail*
example@example.com
Cell Phone Number (Texting)*

Area Code (XXX)Phone Number XXX-XXXX
Secondary Phone Number

Area CodePhone Number
Additional Comments
Please verify that you are human*
PLEASE READ:

The CERT instructor will contact you regarding your request to be in the CERT Hands-On Course. Classes are taught when enough interest has been shown by the public. He will notify you of where the classes will be held and when the first class will begin.
Thank you for your community involvement and your willingness to serve on a CERT team.

If you have any questions about Santaquin City CERT, you can email Chris Lindquist at CLindquist@santaquin.org.
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SANTAQUIN CITY