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                                    Registration Form

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* 1. Full Name as you would like it to appear on your certificate and CERT ID badge

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* 2. Address

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* 3. Will you be attending all eight (8) sessions?

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* 4. Have you already taken CERT Basic Training?

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* 5. If you answered yes to question #4, when did you graduate?

Date

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* 6. Are you interested in being a CERT Disaster Service Worker (DSW)?

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* 7. Are you an Amateur Radio Operator?

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* 8. If yes, what is your call sign?

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* 9. Are you interested in any advanced/supplemental CERT training?
Please select all that apply.

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* 10. Are you registering for someone else?

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* 11. If you answered yes to question #10 please fill out the other participants information.

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* 12. Are you attending this session as a refresher?

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