Union Parish Teen CERT Training (2 Days), Saturdays 2/25 & 3/4/2023

Union Parish Teen CERT Training (2 Days)

Please answer the following questions to confirm your enrollment to attend. This information will be used for documentation of those participating in the Community Emergency Response Team (CERT) training and for the generation of completion certificates. Registration is subject to approval.

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* 1. Name (First and Last)

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* 2. Address

Address

City/Town

State/Province

ZIP/Postal Code

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* 3. Phone Number

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* 4. Email Address

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* 5. Please check whether you are a

Student

Parent

Adult CERT Team Member

School Faculty/Staff

CERT Trainer

Other (please specify)

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* 6. Please provide your parent or guardian's name and phone number if you are a student:

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* 7. Have you completed a Basic CERT course? Yes or No - and if Yes, enter the location and year completed.

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* 8. Please provide your age range (for data collection only)

Under 21

Age 21-44

Age 45-65

Age 65+

Union Parish Teen CERT Training (2 Days), Saturdays 2/25 & 3/4/2023

Union Parish Teen CERT Training (2 Days)

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* 1. Name (First and Last)

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* 2. Address

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* 3. Phone Number

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* 4. Email Address

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* 5. Please check whether you are a

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* 6. Please provide your parent or guardian's name and phone number if you are a student:

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* 7. Have you completed a Basic CERT course? Yes or No - and if Yes, enter the location and year completed.

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* 8. Please provide your age range (for data collection only)

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* 9. Do you have any food allergies or dietary restrictions? Explain...

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* 10. Additional Comments: