Your Full Name: *


Your Email: *


Primary Phone: *


Street: *


City: *


Zip: *


Date of Birth (You MUST be 18 or older to apply): *


Where did you hear about the Barrow County CERT program?:


Tee Shirt Size:


THIS PROGRAM DOES INCLUDE PHYSICAL ACTIVITY. DO YOU REQUIRE ANY SPECIAL ACCOMODATIONS TO PARTICIPATE IN THE PROGRAM? *
Yes
No

If Yes, please explain:


I give permission for any still photography or video footage in which I may appear to be used for whatever purposes deemed appropriate. I do this voluntarily and with the understanding there is no remuneration. In addition, I release any involved agencies and jurisdictions from any liability related to this training. I have read and understand the above requirements and stipulations. I attest that all information on the below application is true.

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I AGREE TO ALL THE CONDITIONS SHOWN ABOVE: *