Cass Clay CERT Registration
Thank you for your interest in our Community Emergency Response Team training. Shortly after you submit this form you will receive an email regarding training dates and times.
Email address *
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Phone Number *
Your answer
Secondary Phone Number
Your answer
Secondary Email Address *
Your answer
Birthday *
MM
/
DD
/
YYYY
Drivers License # *
Your driver license number is needed for background checks.
Your answer
Social Security #
A social security number is needed for workers compensation purposes.
Your answer
How did you hear about the Cass Clay CERT Program? *
Required
Special Skills & Certifications
What is your occupation?
Your answer
Languages spoken *
Required
Any special accommodations?
Your answer
A copy of your responses will be emailed to the address you provided.
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