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2. The Hybrid CERT course is a new self-paced, online course taught in an interactive format including lecture, video, virtual reality-based problem-solving exercises, to be followed by a two-day, in-person disaster preparedness skills workshop.

   Please complete one form per registrant.

4. Class Session

   (i.e. Fall 2021)

5. Date
   Date
7. Name*
8. Email Address*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Home Phone Number*
17. Cell Phone Number*
19. Contact Information*
    -- Select One --I am interested in sharing my contact information with other Yorba Linda CERT Members.I am interested in sharing my contact information with other Yorba Linda CERT Members in my neighborhood.I am NOT interested in sharing my contact information.
21. Please tell us briefly why you are interested in the CERT Program.
23. Please list any previous training in emergency preparedness, first aid and/or safety you have participated in. Please include course title and date completed.
    Previous training is not required.
25. Please list any previous experience in emergency preparedness and/or emeregncy response you have had.
    Previous experience is not required.
27. How did you find out about our CERT Program?

    1. City of Yorba Linda Website
    2. City of Yorba Linda Activity Guide
    3. Yorba Linda Cable Channel
    4. Yorba Linda E-Newsletter
    5. Other City Agency
    6. Newspaper
    7. Friend/neighbor/co-worker
    8. Past CERT Graduate
    9. Other
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field