First Aid & CPR Class Registration and Equipment Order Form
Authorized Provider:
Course Name:
PICK UP Date & Time:
RETURN Date & Time:
Pick Up Location
Lancaster Office: 430 W. Orange Street, Lancaster
Capital Region Office: 1804 N. 6th Street, Harrisburg
Central Juniata EMS, Mifflintown
Contact Name:
Phone Number:
E-mail Address:
Billing Address:
City:
State:
Zip Code:
Instructors:
Class Location:
Class Dates & Times:
Number of Participants:
Is class open to public?
YES
NO
If yes, please explain registration procedure,
including contact person
and phone number:
Special Instructions:
RENTAL EQUIPMENT
(Please enter your requesting quantities.)
Adult Manikins
Infant Manikins
Adult Mouthpieces
Infant Mouthpieces
ER Video Set
SFA/CPR Video
(OLD)
Infant/Child CPR Video
(OLD)
Oxygen Admin Video
CFAS Video
(OLD)
CPR/FPR Video
PDT Video
AED Video
(OLD)
Bag-Valve-Mask
Airway Manikin
Backboard/CID Blocks
AED Trainer (specify)
FA/CPR/AED DVD (ECC 2005)
Please note if you would like to purchase, not rent, a video:
PURCHASE SUPPLIES
(Please enter your requesting quantities.)
Bandage Packs
CPR Training Kit
Keychain Mask
Breathing Barrier
(36 per roll)
Pocket Mask
Soft Case
Pocket Mask
Hard Case
Adult CPR/AED Skill Card
(OLD)
Infant/Child CPR Skill Card
(OLD)
First Aid Skill Card
(OLD)
CFAS Textbook
(OLD)
CPR/FPR Textbook
Emergency Response Textbook
Emergency Reponse Workbook
FA/CPR/AED Part. Bklt
(OLD)
First Aid Skill Card (ECC 2005)
Community and Schools Workbook (ECC 2005)
Adult CPR Skill Card (ECC 2005)
Workplace Participant's Booklet (ECC 2005)
Infant and Child Skill Card (ECC 2005)
PAPERWORK/OTHER SUPPLIES
(There is no cost for these items.)
Course Record
Course Record Add.
FA/CPR Eval Form
Health Precaution Sheet
Splints
I AGREE TO BE RESPONSIBLE FOR THE EQUIPMENT LISTED ABOVE AND RETURN IT IN GOOD CONDITION TO THE AMERICAN RED CROSS OF THE SUSQUEHANNA VALLEY BY THE RETURN DATE AND TIME LISTED ABOVE. I AGREE TO REPORT ANY PROBLEMS OR DEFECTS IN WRITING UPON RETURN OF THE EQUIPMENT.
Type your name after reading and agreeing to the above statement:
Date:
