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CSSD Membership Form

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Create Account
Please complete all the form fields below to create your student account.
Be sure to update your account if any of your personal information changes.

Account Information
* required field
First Name: *
Last Name: *
Please choose one of the following: *
Current Position: *
Address: *
City: *
State: *
Zip: *
Day Phone: *
ex. XXX-XXX-XXXX
Cell Phone: *
ex. XXX-XXX-XXXX
This is only used for class cancellations, emergencies or last minute notifications
Work Email: * (This is your login ID.)
All CSSD Training Calendar information will be sent to this email address.
Alternate Email: *
This is only used for class cancellations, emergencies or last minute notifications.
Who manages your account:
Supervisor Name: *
Supervisor Contact Info: * Phone or Email
Password: *
Confirm Password: *
Have you previously had a student account on this CSSD Training Registration website?

The email address you provide serves as your account user name.

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