Seven Mountains EMS Council

American Heart Association BCLS Training Center

Training Center Instructors:  Please complete the following information to register & schedule a CPR course.

  1. Instructor Contact Information:

    First Name
    Last Name  
    Organization
    Work Phone
    Home Phone
    E-mail

     

  2. Name of Course:        

  3. Type of Course:
                                Basic Course
                                Refresher Course

  4. Course Date:        -- mm/dd/yy
     

  5. Course location, time, & additional class sessions:



  6. Is course open for additional students?

    YES
    NO

  7. Supplies Needed:

    Nothing Needed
    Kit Only (tests & videos)
    Individual items (list items below)
    Class package
    *NOTE: Course exams need to be maintained in a secure manner, so kits can not
    be released to non-instructors and instructors are responsible for security
    until returned to Council.
     

  8. Number of Students:        
     

  9. Date of Equipment Pick-up:                    -- mm/dd/yy
     

  10. Date of Equipment Return:                    -- mm/dd/yy
    *Equipment, especially the course kits, need to be returned ASAP as other
    instructors may have scheduled it's usage.
     

  11. Please provide the following ordering information: 
    (See Available Texts, Equipment & Supplies List)

    QTY DESCRIPTION

     

  12. Comments:


    *NOTE: Course completion cards can not be issued until we receive: completed course roster,
    evaluation summary, written (depending on course) & practical examination answer sheets.
    Normal turn-around time is usually less than 5 working days.

S. Rhoat Creations
Copyright © 2005 Seven Mountains EMS Council. All rights reserved.
Revised: January 20, 2009