CERT | RACES Registration Form

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Privacy Notice: This form is not submitted online. All information entered stays on your device until you download the PDF. No data is transmitted to the City until you submit the completed form via email to CERT@fullertonfire.org or in person.

Please complete one registration form per participant. Provide your personal information, emergency contact information, and answer the questions below. Include copies of any training certifications when you submit this form.

1. Volunteer Program

Please select which program(s) you would like to volunteer for. You may select both.

CERT (Community Emergency Response Team)

RACES (Radio Amateur Civil Emergency Service)

2. Personal Information

Full Name *

Date *

Email Address *

Phone *

Cell Phone (if different)

Street Address *

City *

State *

ZIP *

3. Emergency Contact (in case of emergency, please contact:)

Contact Name *

Relationship *

Phone *

4. Second Emergency Contact (optional)

Contact Name

Relationship

Phone

5. Previous Training in Emergency Preparedness, First Aid, or Safety

List any previous training you have participated in (e.g., ICS 100, ICS 200, Red Cross, CMAP Trained). Please attach copies of certifications when you submit this form. Use additional rows or a separate sheet if needed.

Course Title

Date Completed

6. CERT or RACES Roles

Roles Experienced or Interested In

7. Other Languages Spoken (optional)

Language skills are valuable during emergency response. Please indicate any languages you speak in addition to English.

Other Languages (not listed above)

8. Electronic Signature

I agree to sign this document electronically. I understand that my typed name below constitutes a legally binding electronic signature under the California Uniform Electronic Transactions Act (Civil Code § 1633.1 et seq.) and has the same legal effect as a handwritten signature.

Type Your Full Legal Name to Sign *

Date Signed

By typing your name above, you are signing this document electronically. A timestamp and record of this signature will be included in the generated PDF.

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CERT | RACES Registration Form

CERT / RACES Registration