Request Group Training Form

First name

Last name

Email

Phone number

Alternate contact person or contact method

Alternate phone number

Company/Organization name

Company/Organization address

Type of Class You are Requesting
Basic Life Support Renewal - $950 for 1-10 studentsAdult First Aid CPR AED (Optional: Infant & Child Modules) - $1,140 for 1-12 students

Are you requesting a blended/ hybrid option of training?
[radio* blended-hybrid-option use_label_element default:1 "yes" "no"]

Number of Expected Students

Class Date(s) and Time(s) You are Requesting

Training Location

What Type of AED do you have?
[radio* aed-type "onSite" "FRx" "I dont know" "We dont have one and need assistance purchasing an AED unit for our location." "Other"]

Please use this space to request special accommodations or provide us with additional information that can be helpful as we begin to plan for the training class.