(Please
Print or Type Information)
Name:
Address: Daytime Phone:
City: State:
Zip: Evening Phone:
Name of course(s) Cost Course Date(s) Time Location
_____
_____
Total:
For CPR recertification courses, please indicate below
the type of CPR you are recertifying (i.e. Adult CPR, Infant & Child CPR,
CPR for the Professional Rescuer), as printed on your original certificate.
CPR Recertification for:
_
No Mail in registrations for Fundamentals of Instructor
Training (FIT) or any instructor classes will be accepted. You may register at the pre-requisite
in-person interview.
I would like to purchase (please indicate quantity): ____ Res-Cue Mask
____ First Aid Fast Booklet ____ Babysitter’s Training and
First Aid Kit
____ Mini Personal Protection Pack ____ The Personal
First Aid Kit
____Gift Certificate______Amount
____Pillow First Aid Kit
Total:
Method of Payment:
q Cash q Check,
to American Red Cross
q Visa q
Master Card q
Discover q
American Express
Credit Card Number:
Expiration Date:
Name on Card:
____________________Signature:_________________________
Amount Enclosed :
Return To : American
Red Cross or Fax
To: (269)353-8657
|
For Office Use Only: Date of Payment: ___________
Receipt Number: ______________ Scheduler’s Initials: _____ |