COLORADO ADVANCED LIFE SUPPORT



TCF or Instructor:       TCF or Instructor Email:      

TCF or Instructor Phone #:       Date(s) of Program:      /     /      to      /     /     

Training Site:       Address:      

City:       State:       Zip:      

Type of Program:

Healthcare Provider Healthcare Provider (Renewal) Healthcare Provider Skills Check-off BLS Instructor

Heartsaver CPR/AED Heartsaver First Aid/CPR/AED Heartsaver First Aid Skills Check off

Heartsaver First Aid Heartsaver Pediatric FA Heartsaver CPR/AED Skills Ck off Heartsaver Instructor

The course for which you are enrolled may include physical strain, possibility for cross infection, and emotional stress. CPR is very strenuous both in practicing on the manikin and performing CPR on a cardiac arrest victim. If you have any medical conditions or cardiovascular disease history that may be aggravated by this course, please consult your physician as to whether you should participate in a CPR course. If you have any reservations about your ability to perform CPR on a cardiac arrest victim, you may want to reconsider taking this course. If you have recently had any infectious disease, including upper respiratory infection or open sores on your mouth and/or on hands, it is imperative to defer manikin practice. The AHA and its CTCs are not certifying agencies. The AHA and its CTCs are not responsible for the level of classes taught to participants.

By filling in my name by hand or by typing below I have acknowledged that I have read all the above statements and absolve the American Heart Association, its CTCs, and instructors from any liability associated herewith. I do not currently have any infectious disease.

| |Name |Address |Exam Score |Status: |Remediation/Date Completed |

| |      |      |      | Complete |      |

|1 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|2 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|3 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|4 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|5 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|6 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|7 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|8 | | | |Not Yet Complete | |

| |Name |Address |Exam Score |Status: |Remediation/Date Completed |

| |      |      |      | Complete |      |

|9 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|10 | | | |Not Yet Complete | |

| |      |      |      | Complete |      |

|11 | | | |Not Yet Complete | |

|12 |      |      |      | Complete |      |

| | | | |Not Yet Complete | |

|13 |      |      |      | Complete |      |

| | | | |Not Yet Complete | |

|14 |      |      |      | Complete |      |

| | | | |Not Yet Complete | |

|15 |      |      |      | Complete |      |

| | | | |Not Yet Complete | |

|16 |      |      |      | Complete |      |

| | | | |Not Yet Complete | |

|Assistant Instructors/Specialty faculty (attach a copy of instructor card for instructors aligned with other than the primary TC |

|Name |Inst Card Exp date |Name |Inst Card Exp date |

|1.       |      |4.       |      |

|2.       |      |5.       |      |

|3.       |      |6.       |      |

The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, PEARS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association. Any fees charged for such a course, except for a portion of fees needed for AHA course material, do not represent income to the Association.

I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines.

Date:      /     /     

This form and course evaluations need to be submitted to Colorado Advanced Life Support, Inc. within 30 days of course completion.

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