CERT Course Registration Form

SANTAQUIN CITY

CERT Registration Form
Today's Date*

MonthDayYear
Date mm-dd-yyyy
Student Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
Verify E-mail*
example@example.com
Cell Phone Number (Texting)*

Area Code (XXX)Phone Number XXX-XXXX
Secondary Phone Number

Area CodePhone Number
Additional Comments
Please verify that you are human*
PLEASE READ:

The CERT instructor will contact you regarding your request to be in the CERT Hands-On Course. Classes are taught when enough interest has been shown by the public.
Thank you for your community involvement and your willingness to serve on a CERT team.

If you have any questions about Santaquin City CERT, you can email Chris Lindquist at CLindquist@santaquin.gov.
Should be Empty:

SANTAQUIN CITY