Class Sign-Up Form

(Spring class starting April, 2012)

By filling out the form below you are expressing interest in the upcoming Newark CERT classes.  This pre-registration does not obligate you, but gives us a way to send you a reminder as the class approaches or if the schedule changes.  Fields marked with an asterisk * are required.  As always, your information is kept strictly confidential and is used only for pre-registration and organization of volunteers in an emergency.  Thank you for taking the time to make CERT great!

First Name *
Middle
Last Name *
Address (number and street) *
Apt. #
City, State Zip Code (if other than Newark)
Phone Number (please provide at least one phone #)
Cell Number
E-mail Address *
Which elementary school district do you live within?	----Bunker Elementary/NMHSGraham ElementaryKennedy ElementaryLincoln ElementaryMilani ElementaryMusick ElementarySchilling ElementarySnow Elementary
Do you wish to be contacted? *	Yes  No
Comments or questions:
Please type the letters and numbers shown in the image.