Course Registration Form
Please fill in all fields marked with a *.

Please complete and submit your registration. In order to register you must also leave a
deposit on-line using Paypal. Please note: deposits are non-refundable.
If you cancel 48 hours in advance, the deposit will be applied to a future course.
Cancellations with less than 48 hours notice will result in loss of your deposit.
Deposits are required for all courses. $20.00 for CPR and First Aid courses, $75.00
for ACLS/PALS/Instructor courses.
First Name *
Middle Name *
Last Name *
Address *
City *
State *
Zip *
Phone *
Email *
Course Name *
f Date *
Fees *

              

 
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