The Colorado Cardiopulmonary Resuscitation Association Phone: (303) 980-1015 ∞ 4380 S. Syracuse St. Suite 300. Denver, CO 80237 ∞ Fax: (303) 980-6375 Email: email@example.com ∞ Website: www.cocprassn.com We thank you for printing legibly! Course Roster Instructor Information Lead Instructor (Print) _____________________ Card Renewal Date ___/___/____ Address ____________________________________________________ City, State, Zip ____________________________/______/____________ Phone (H) ____________________ Phone (W) _____________________ Course Location ______________________________________________ Instructor email ______________________________________________ Payment Information Check enclosed (Payable to Colorado CPR) CK#____________ Credit Card # _______________________________ Exp date ____/____ Account Deduction (Specify account holder’s name) _________________________ Monthly Invoice (Specify company, must be set up for this option) __________ ________ Cash Course Information Course Date ___/___/___ Total Number of Students in Course _____ Card Information Mail cards to _________________________________________ ____________________________________________________ __ Send typed cards to location indicated ($6.00/ card) ___ Send typed cards to students ($7.00/ card) ___ E-cards released in account in Instructor Network ($5.00/card) **Please note: Cards are sent via regular mail. The CPR Association is NOT responsible for lost cards. If cards are lost, there is a replacement fee of $15 each . For an additional $20, we will send cards via UPS for tracking purposes. If there is only one student, there is still a $15 charge for sending the card direct. If you wish to email or fax your roster, there will be a $1 processing fee per page. Mark ONE course box in accordance with the video and books that were used, including checking all modules that were completed. Note, only one course should be filled out per roster. If students completed different modules, they must be submitted on a separate roster. BLS Provider – New ____ Recertification___ Online Check Off (with certificate) ____ Heartsaver Adult First Aid with CPR/AED – Adult CPR/AED ____ Child CPR/AED ____ Infant CPR/AED ____ o Online Check Off (with certificate) ____ Heartsaver CPR/AED – Adult ____ Child ____ Infant ____ Online Check Off (with certificate) ____ Heartsaver First Aid — Course ____ Online Check Off (with certificate) ____ Pediatric First Aid – Adult CPR/AED ____ Child CPR/AED ____ Infant CPR/AED ____ ACLS Provider – New ____ Recertification ____ Instructor – New (With Essentials Certificate) ____ Re-Cert ____ I attest that this course has been conducted under standards and procedures established by the American Heart Association. [Please Print & Sign] Signature of Lead Instructor x___________________________________ Assistant Instructor x___________________________________ Revised 04/16 Per AHA Guidelines, this form must be turned into the CPR Association within 20 days of course date. Colorado CPR Association Liability Statement 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 hands, it is imperative to reschedule your course. Please note: You will have to be physically able to perform your CPR skills on the floor. ***I have read all the above statements and absolve The Colorado CPR Association and The American Heart Association and instructors from any liability associated herewith. I do not currently have any infectious disease. NOTE TO ALL INSTRUCTORS AND STUDENTS: Colorado CPR is not responsible for misspelled typed cards due to illegible handwriting. Please PRINT legibly. We can re-issue cards due to illegible handwriting for a fee of $15 per card. Thank you! Student Name Print Legibly Mailing Address: City, State and Zip Code OR eCards : Email address Phone Number Card Expiration Course Including Area Code Date Percentage 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Revised 4/16 Per AHA Guidelines, this form must be turned into the CPR Association within 20 days of course date.