Registration Form

Complete the following form to create an account for use inside the campus. The information collected here will not be shared with any third-party and is used solely for providing services inside the campus. 


What would you like to do ?

How did you hear about us ?

Participant Information

* First Name:  

* Last Name:  

Middle Initial:  

* Title ⁄ Rank ⁄ Position:  

* Date of Birth:  
* Are you a US citizen?
 
* Are you an American Red Cross Volunteer?
 

Agency Information

* Agency,University,Association or Company Name:   * If you do not have an agency or company, please specify "N/A" for Agency Name and provide personal contact information below.

* Work Address:  

* City:  

* State:

* Zip Code:  

If non-US, specify the country:  

* Phone #: Type:

* Number:  

Extension:  

* Email Address:  

* Verify Email Address:  

Years in Agency:  

Level of Government - Select one item best describing your level of government.

 *

Student Discipline - Select one item for your primary student discipline.

 *

Eligibility

I have reviewed the necessary requirements for this training (in Course Descriptions ) and I certify that I meet these requirements.

*
 

If No, please explain:

I certify that I meet the U.S. citizen requirement.

*
 

I am willing to participate in a post-class evaluation consisting of a phone call or email to help the NCBRT make improvements to classes and collect feedback on how course information is being applied in the field.*

By submitting your registration information, you indicate that you agree to the Terms of Use and have read and understand the NCBRT eLearning Privacy Policy.

 

Business hours disclaimer:

Regular business hours are Monday through Friday, 7:00 am to 4:30 pm (Central time). Requests made on weekends, holidays, and/or outside of regular business hours will be addressed as soon as possible.

Citizenship disclaimer:

Participation is currently limited to United States citizens unless a special request form is completed. Once the form is reviewed, you will be notified via email the status of your account.

*Confidentiality of Information:

The training evaluation forms have been designed to solicit your assessment of enhanced knowledge and skills related to the course objectives and any actions you plan to take to enhance your capacity or that of your agency to respond to a terrorist attack. The information will be used by the Department of Homeland Security — FEMA to modify or enhance the training course to better meet the needs of emergency responders and to address changing terrorist threats. Although your feedback is very important to us, completion of the form or specific questions is voluntary. The personal identifying information is requested so that we can conduct a follow-up survey on the usefulness of the course to you. Your responses and all personal information will remain confidential. Any reporting of the data will be done anonymously in an aggregated fashion, without names or identifiers.