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2. 1. Personal Information
4. Last Name
5. First Name
6. Middle
8. Street Address
10. City
11. State
12. Zip Code
14. Home Phone
15. Cell Phone
17. Email Address
19. 2. Work Information
21. Occupation
23. 3. Emergency Contact Information
25. First Name
26. Last Name
28. Home Phone
29. Cell Phone
31. 4. List applicable additional training, certification, work or life experience

    (i.e. medical, emergency response, red cross, military service)

33. 5. How did you hear about the CERT class?
35. Waiver/Photo Release

    I understand that the City of Lake Elsinore reserves the right to use photos taken during events/projects for promotional purposes.  This could include publishing in newsletters, brochures, and the City of Lake Elsinore Website.

37. Electronic Signature (Type Full Name)*
38. Date
    Date
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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