CERT Training / Membership Application

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Sun City Area Community Emergency Response Team
Membership Application - please be as complete as possible. Your privacy is important, information is only shared internally on an need to know basis.

Date

YYYY

CERT Team Application or CERT Basic Training ? *

I am registering to attend a CERT Basic Training Class

I have already attended a CERT Basic Training Class and want to join a team

Full name *

First and Last Name

Preferred name

Nick name (if any)

Home Address *

Number, Street, City, ST, Zip

City / Village or Sub-Division

Mobile Phone # *

Mobile Phone Carrier / Provider

Email Address *

Preferred email address

Emergency Contact

Emergency Contact Phone Number

Are there any medical concerns you would like to share with us?

(History / Medications / Allergies Etc.)

Are you bilingual?

Yes

Clear selection

Are you a Seasonal Resident?

Yes

Clear selection

Clear form

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Forms

This form was created inside of Sun City Center CERT.