Training Order Form - Via Heart Project

Name

Ordered by/Billed To:

Company *

Ordered by/bill to Address *

Ordered by/bill to City *

Ordered by/bill to State *

Ordered by/bill to ZIP *

Ordered by/bill to Phone *

Ordered by/bill to Email *

Ordered by/bill to Contact Name *

Choose Your Class:

The AHA’s Heartsaver courses are designed for anyone with little or no medical training who needs first aid and/or CPR training and a course completion card for job, regulatory (i.e. OSHA), or other requirements. Heartsaver courses can also be taken by anyone who wants to be prepared to act in an emergency.

CPR/AED Class with certification:

Class length is 2 hours. Instructors come to your site with all supplies and manikins. Class size is for up to 10 people. Certification for 2 years.

FIRST AID Class with certification:

Class length is 2 hours. Instructors come to your site with all supplies. Class size is for up to 10 people. Certification for 2 years.

CPR/AED/FIRST AID Class with certification:

Class length is 3.5-4 hours. Instructors come to your site with all supplies and manikins. Class size is for up to 10 people. Certification for 2 years.

Certification cards will be emailed within 21 days of course completion.

Live, virtual classes are available for CPR/AED. Practice manikins will be sent to each student in advance and will be returned to us after the class.

CPR/AED Certified Class ($800)

Please select the number of classes (NOT number of participants)

VIRTUAL LIVE-CPR/AED Certified Class ($900)

Please select the number of classes (NOT number of participants)

First Aid Certified Class ($800)

Please select the number of classes (NOT number of participants)

CPR/AED/First Aid Class ($1,200)

Please select the number of classes (NOT number of participants)

Training Location Details: and on-site contact person for the day of the training

Company *

Day of Training On-Site Contact Name *

Day of Training On-Site Contact Phone *

Day of Training On-Site Contact Email *

Training Site Address (If class will be virtual, please type VIRTUAL below) *

Training Site City *

Training Site State *

Training Site ZIP *

Preferred Training Date. Please provide 3 tentative dates and start time for your training day, 3 - 6 weeks from today. *

Covid-related protocols: What COVID-related protocols do you have in place that our Instructors will have to comply with (i.e. temperature check, health questionnaire, wearing of mask, etc.)? *

Training Venue - Room Setup Requirements
General guide only – we cater to small and large venues Please advise us in advance if your venue does not meet the requirements below so we can assist you: - Adequate floor space to accommodate all participants (for CPR and recovery position plus scenarios) - Suitable heating or cooling depending on whether conditions for your staff comfort - Training area is carpeted or you have mats or towels available for everyone to kneel/lie on - Space for a projector screen (white whiteboard/wall) at the front of the class (with small table for laptop and projector) - Contact person should be at the venue 45 mins prior to the start time to let the Instructor in and to assist with setting up - Arrange parking close to training room to assist with unloading of equipment (or staff to assist) Training space be set up when possible in a U-Shape (chairs only).

Does your venue meet the requirements listed above? *

Yes

Virtual Class

Will the contact person, or staff, arrive 45-60 minutes prior to the start time to let the trainer in and assist with setting up equipment? *

Yes

Virtual Class

Is parking available at the training venue? *

Yes

Virtual Class

If yes, please provide instructions.

If no, please provide information about nearby off site parking. Free street parking? Meters? Paid Parking?

Do you have a projector and/or a place to project available for use on the day of the training? *

Yes

Virtual Class

Cancellation or Rescheduling: We must be notified at least 5 business days prior to the course date if there is a need for your company to cancel or reschedule, otherwise a $500 fee is applicable per session (per trainer scheduled). Life Support Solutions reserves the right to cancel a booking for any unforeseen circumstances and will reschedule the training on a suitable date (no refund or discounts will be provided if we are required to reschedule a booking). *

I have read and agree to the terms described above.

Invoices: Invoices will be emailed to the contact person listed on this booking form. They will be sent from Via Heart Project. *

I have read and agree to the billing terms described above.

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