2004 HCP Course Roster
[pic]
American Heart Association Emergency Cardiovascular Care Programs
Heartsaver®
Course Roster
|Course Information | |
( Heartsaver CPR AED Lead Instructor ______________________________________
( Child CPR AED ( Infant CPR ( Written Test
Status: ( Heartsaver ( BLS HCP
( Heartsaver First Aid CPR AED Status Renewal Date _______________________________________ ( Child CPR AED ( Infant CPR ( Written Test Training Center ___________________________________________
Training Center ID# _______________________________________
( Heartsaver First Aid Training Site Name (if applicable) ____________________________
( Written Test Course Location __________________________________________
Address _________________________________________________
( Instructor City, State ZIP ____________________________________________
( Provider
Course Start Date/Time _______________ Course End Date/Time _________________ Total Hours of Instruction __________
No. of Cards Issued _________ Student-Manikin Ratio __________ Issue Date of Cards ________________
|Assisting Instructors (Attach copy of instructor card for instructors aligned with a TC other than the primary TC) |
|Name and Instructor ID# Card Exp. Date |Name and Instructor ID# Card Exp. |
| |Date |
|1. |5. |
|2. |6. |
|3. |7. |
|4. |8. |
I verify that this information is accurate and truthful and that it may be confirmed. This course was taught in accordance with AHA guidelines.
____________________________________________ _______________________________________________
Signature of Lead Instructor Date
Date _________________ Course ___________________________ Lead Instructor _____________________________________
Course Participants
|Name and Email |Address/Telephone |Complete/ |Remediation Date Completed |
|Please PRINT as you wish your name to appear on your card. Please print | |Incomplete |(if applicable) |
|email address legibly. | | | |
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