Hybrid CERT Training

Interest Form

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* 1. First Name

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* 2. Last Name

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* 3. Contact Information

Address

Address 2

City/Town *

State *

Zip/Postal Code *

Home Phone Number *

Work/Office Number *

Cell Number

Email Address *

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* 4. Emergency Contact

Name

Phone Number

Additional Number

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* 5. Have you had CPR training?

Yes

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* 6. If you answered yes above, please provide the date of your CPR training:

Date / Time

Date

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* 7. Have you had first aid training?

Yes

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* 8. If you answered yes above, please provide the date of your first aid training:

Date / Time

Date

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* 9. Are you a ham radio operator?

Yes

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* 10. If you answered yes above, what is your call sign:

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* 11. Do you have any additional information or comments that you would like to share?

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* 12. How did you hear about the CERT training program?

CERT member or leader

Health or Info fair

Cable T.V.

School

Newark News

Newark Days

Newspaper

City of Hayward website

City of Hayward Email

Social media (Facebook, Instagram, Twitter, Nextdoor etc.)

Other (please specify)