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EMR Class Registration
If you (the student) do not have a Healthcare Provider level CPR card then enter "None" for the fields about your CPR card below the line.
Only enter the STUDENT's information below:
*
Student First and Last Name
*
Agency Name
*
Student Email
*
Student Phone Number
*
Has your agency approved you to attend this training?
Yes
No
*
I have a current Healthcare Provider level CPR Card (Answer No if your card will expire within 3 months after course completion date)
Yes
No
*
Enter the Title of your CPR Card (e.g., BLS Provider, Professional Rescuer, etc.) or None if you do not have one or will expire within 3 months after course completion date.
*
Enter Certifying Agency for your CPR card (e.g., AHA, Red Cross, National Safety Council, etc.) or Enter NONE if your card will expire within 3 months after course completion date
*
Enter Expiration Date of your CPR card or None:
*
I understand BLS/Healthcare provider level (or equivalent) CPR certification is required and that I must submit a copy of my card to the Course Director before the course end date:
Yes
No
*
I agree by entering my name here and submitting this registration form to pay the $400 cost of the EMR class.
NOTE:
Cancellations must be made by Friday, August 27th, if not, your agency will be invoiced in full ($400). Substitutions will be accepted.
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