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CERT Training Registration Form

2. First

3. Middle

4. Last

6. Street

8. City

9. State

10. Zip

12. Email

14. Daytime Phone

15. Evening Phone

17. Neighborhood

19. Select Preferred Class Date

    1. January 7 (evening class)
    2. Notify me when a new class is scheduled

21. CERT Program Media Release

    1. I Agree

    “By registering for a CERT Basic Class and becoming a member of the Chesterfield County CERT Program I agree that Chesterfield County and its authorized representatives may record or photograph my participation. I further agree that any such materials may be used, in any form, as part of any future publications, print materials, brochures, or other digital media used to promote Chesterfield County, and further that such use shall be without payment of fees, royalties, special credit or other compensation.”

23. Check Other Programs With Which You Are Affiliated

    Check all that apply.

    1. Neighborhood Watch
    2. Medical Reserve Corps
    3. Citizens Police Academy
    4. Citizens Fire Academy
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field