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4. Welcome to the Brea Community Emergency Response Team C.E.R.T. Class Registration Form. The C.E.R.T. class is a 20 hour course taught in an interactive format including lecture, video, discussion, and hands-on activities. Please fill out one registration form per participant.
6. Date
   Date
8. Name
9. E-Mail Address
11. Address
13. City
14. State
15. Zip
17. Home Telephone
18. Cell Phone
20. Please tell us briefly why you are interested in the CERT Program:
22. Please list any previous training in emergency preparedness, first aid and/or safety you have participated in (previous training is not required). Please mention the course title and date completed.
24. Please list any previous experience in emergency preparedness and/or emergency response you have had (previous experience is not required).
26. How did you find out about our CERT Program? (Please check/fill out all that apply).

    1. Brea Line
    2. City of Brea Website

    1. City of Brea Cable Channel
    2. Newspaper

    1. Friend/neighbor/co-worker
    2. Church
28. By clicking agree, I understand to have my information submitted.

    1. I agree
Leave This Blank:


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

    This field is not part of the form submission.

32. Submit

* indicates a required field