*All participants must be
60 years of age or older
*All participants must be
Yorba Linda residents
Please send this registration form for lifetime ridership to:
Parks & Recreation Department - Yorba Linda Community Center
Phone: 714-961-7181
4501 Casa Loma Avenue
Yorba Linda, CA 92886
FAX: 714-986-1025
To schedule a trip after registration confirmation, please call 855-210-5147
Name: _______________________________ Housing Complex (if applicable):__________________________
Address: _____________________________ Telephone: ___________________________________________
City: ______________________________ Zip Code: ________________ Date of Birth:_________________
Gender: Male Female Marital Status: Married Widowed Separated Single Divorced
1. Do you require any special accommodations? Yes No
If yes, please describe: (i.e. use wheelchair, blind, deaf)
2. Who should we contact in case of an emergency?
Name ____________________________Telephone ___________________________
Relationship ___________________________________________________________
Alternate: Name _____________________________ Telephone ________________________
Relationship ___________________________________________________________
Doctor: Name _____________________________ Telephone ________________________
Address _______________________________________________________________
3. Cancellation Policy: All cancellations must be made 2 hours before your scheduled pick-up time. Three
cancellations recorded within a month period will result in suspension from riding the service for 30 days. Any
cancellations made after the 2 hour window will be recorded as a no show. Three no shows recorded within a one
month period will result in suspension from riding the service for 30 days. An early cancellation allows us to
reassign the time slot to someone else.
___________________________________ ________________________________
Applicant’s Signature Date
Date Received: ______________ Verified: 60 & over Received by : ______________
Department Use Only
ID NUMBER YBL_________
Taking Retired Adults Into Local Services