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Last updated 3/20/2019 GP

Riverside City

Community Emergency Response Team

Preparing today for tomorrow’s emergencies!

COURSE REGISTRATION FORM STEM LEAPS FIRE CERT TRAINING

APPLICANT INFORMATION PLEASE PRINT NEATLY

NAME

LAST FIRST M.I.

ADDRESS

CITY

ZIP DATE SUBMITTED:

HOME PHONE : CELL PHONE :

STUDENT E-MAIL:

PARENT E-MAIL:

SCHOOL ATTENDING:

Birth date

Month Day Year

PARENT/ LEGAL GUARDIAN PRINT NAME PARENT/ LEGAL GUARDIAN SIGNATURE: (REQUIRED)

COURSE INFORMATION

√ SESSION COURSE TYPE LOCATION DATES AND TIMES

STEM LEAPS FIRE CERT JULY 2019

CLASS

FEMA CERT Basic

COURSE

Riverside City Emergency Operations

Center 3085 St.

Lawrence St, Riverside, CA

92504

TUESDAY JULY 9 - 8:00 AM TO 5:00 PM

WEDNESDAY JULY 10 - 8:00 AM TO 5:00 PM

** MUST ATTEND BOTH DAYS TO

COMPLETE TRAINING CERTIFICATION

Class Schedule Subject To Change Without Notice Do you require special accommodations for a disability? If so, please describe accommodations requested below:

RETURN COMPLETED FORMS TO: GINA PEREZ- PUBLIC EDUCATION COORDINATOR at: gperez@riversideca.gov

City of Riverside Fire Department 3085 St. Lawrence St, Riverside, CA 92504

PHONE (951) 320-8100 http://riversideca.gov/fire/specialprograms/cert/

CERT MOTTO: “DOING THE GREATEST GOOD FOR THE GREATEST NUMBER OF PEOPLE”

Riverside Fire Department Office of Emergency Management

FEMA – CERT Online registration at:

www.riversideca.gov/readyriverside/cert/

3085 St. Lawrence St, Riverside, CA 92504 Info call (951) 320-8100

Email: rivcitycert@riversideca.gov

STUDENTS UNDER 18 YRS OLD- MUST HAVE PARENT/ LEGAL GUARDIAN SIGNATURE TO ATTEND