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2. 
3. Community Emergency Response Team Training Application
5. Name
6. Email Address
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
15. Fax Number
17. What Interested you in this training?
19. Do you have any disaster response related training or experience?
21. Are you currently certified in:

    1. CPR
    2. AED
    3. First Aid
22. Licensed Amateur Radio Operator? (if yes indicate call-sign and class)
23. Call Sign
24. Class
26. Are you Licensed in any of these fields?

    1. Medical Dr.
    2. DVM
    3. RN
    4. LPN
    5. Paramedic
    6. EMT
27. Do you feel you are physically Fit to participate in this program?

    1. Yes
    2. No
28. Are you previously CERT qualified

    1. Yes
    2. No
30. CERT Training

    After submission of this application, you will receive a correspondence from the CERT Coordinator, Mr. Scotty Johnson, with additional information.

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field