FAIRFAX GOV'T GROUP ONSITE REGISTRATION

AHA Heartsaver CPR (2 year cert.) or First Aid (3 year cert.) Medication Administration Training

Please use this form to request group training at your job site.

Contact Person (Must be available at course site 30 minutes prior to course)

Desired Time:

AM PM

First Name:

Last Name:

Emergency / After Hours Phone:

Facility / Organization / Department

E-mail:

Business Address:

City, St, Zip:

Business Phone:

Fax:

Location of course / Training Room:

TV/VCR Reserved (min size 27"):

Yes No

Parking Instructions

Approx. # of participants:

Session #1 Session #2

Course requested by:

ALL COURSES ARE TAUGHT AND TESTED IN ENGLISH
(Accommodations for language challenges must be made in advance)

Available Courses Course sizes min. 8 / max. 36	Dates Requested Show 1st and 2nd Choice Date and Time	Rate
First Aid Certification 4 hours	(1)	$35.00
First Aid Certification 4 hours	(2)	$35.00
Adult CPR 3 Hours	(1)	$43.00
Adult CPR 3 Hours	(2)	$43.00
Adult & Pediatric CPR** 4 Hours	(1)	$43.00
Adult & Pediatric CPR** 4 Hours	(2)	$43.00
Adult CPR/AED 4 Hours	(1)	$63.00
Adult CPR/AED 4 Hours	(2)	$63.00
Healthcare Provider 3 Hours Retraining Only	(1)	$68.00
Healthcare Provider 3 Hours Retraining Only	(2)	$68.00
Medication Administration Training	(1) (2)	$100.00

The HeartStarts Team