Join Us

Complete form, submit and you will be contacted when a new class will be starting

All fields need to be completed

Exhibitor

Your Name

Home Address

City

Home Phone

Cell Phone

Work Phone

Your Email (required)

Date of Birth

Employer, if applicable

Position/Title

Drivers License and Type

Emergency Name and Contact Info

How did you hear about CERT and CERT Training?

Have you ever been arrested?
YesNo
If yes, please explain below:

This program does include some physical activity. Do you require any special accommodations to participate. If yes, please explain

Why do you want to attend CERT training?

Please provide information about your interests, community involvement and previous training or experience.

I understand a background will be conducted on all applicants. I authorize a background check on me based on this application. I give permission for any still photography or video footage in which I may appear to be used for whatever purpose deemed appropriate. I do this voluntarily and with the understanding there is not remuneration. In addition, I release any involved agencies and jurisdictions from any liability related to this training. All information on the above application is true.

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Bethany Emergency Management