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Interest Form

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* 1. First Name 

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* 2. Last Name

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* 3. Contact Information

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* 4. Emergency Contact

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* 5. Have you had CPR training?

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* 6. If you answered yes above, please provide the date of your CPR training: 

Date

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* 7. Have you had first aid training?

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* 8. If you answered yes above, please provide the date of your first aid training:

Date

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* 9. Are you a ham radio operator?

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* 10. If you answered yes above, what is your call sign:

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* 11. Do you have any additional information or comments that you would like to share? 

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* 12. How did you hear about the CERT training program?

0 of 13 answered
 

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