REGISTRATION

To receive your discount voucher, please complete the following form and submit. Once information has been received and qualification is confirmed, an e-mail will be sent to the address supplied which will contain the discount code and instructions. Thank you for your interest and support. Please read our Privacy Statement regarding the information we collect.

First Name:
Last Name:
City:
State:
Zip Code:	(5 digits)
Daytime Phone:
Email:
Occupation/Profession:

Course type needed:
Do you have student manual?: (required for most classes)
	I am currently certified
Request a month & day for class: please see our class schedulefor BLS and Heartsaver courses. (if private class - leave blank)
Month:
Day of Month:

Comments:	Enter comments here!
Private class request: (Choose a day of the week that best suits you -PREMIUM FEES applicable)	Private Class Request