EMR Class Registration

If you do not have a CPR card then enter "None" for the fields about your CPR card below the line.
 
* Your First and Last Name 
* Agency Name 
* Your Email 
* Your Phone Number 
* Has your agency approved you to attend this training?Yes No 

* I have a current CPR CardYes No 
* Enter the Title of your CPR Card (e.g., BLS Provider, Professional Rescuer, etc.) or None if you do not have one. 
* Enter Certifying Agency for your CPR card (e.g., AHA, Red Cross, National Safety Council, etc.) or None if you don't have one. 
* 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 class. 
 
NOTE: Cancellations must be made by Friday, August 28th, if not, your agency will be invoiced in full ($400). Substitutions will be accepted.
 

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