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2. First and Last Name*
4. Email Address*
6. Phone Number*
8. Home Address (e.g. 1210 Golden Gate Dr, Papillion, NE 68046)*
10. County of Residence*
12. Scheduling*

    1. I'm interested in and available to attend the fall 2023 class in Bellevue (10/13 6pm-9pm, 10/14 8am-5pm, 10/15 8am-5pm).
    2. I'm interested in attending a future class. Please let me know when additional classes are scheduled.
14. By submitting this form you grant us permission to contact you about the CERT program.
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15. Submit

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