EastTex Regional CERT Training and
Membership Registration Form

Class you plan on attending: Class you plan on attending: Transfer from another CERT team

First Name

Last Name

Phone

Cell

Email Address

Drivers License #

Birthdate (mm/dd/yyyy)

Address

City

Zip

Shirt Size (only if you plan on joining the deployment team)

Emergency Contact

Phone #

Emergency Contact

Phone #

How did you hear about us? How did you hear about us? Community Outreach Friend/Neighbor Website Social Media Other

Do you work or live in the Town of Sunnyvale, or Rockwall, Hunt, Kaufman, Collin, or Van Zandt Counties? Do you work or live in the Town of Sunnyvale, or Rockwall, Hunt, Kaufman, Collin, or Van Zandt Counties? Yes No

Where else do you volunteer time?

List any special skills that can be utilized in a disaster