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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Phone Number*
15. Email Address*
17. Heartsaver CPR/AED Course Date*

    Please choose a 2023 course date.

    1. Jan 5
    2. Feb 2
    3. Mar 2
    4. Apr 6

    1. May4
    2. June 1
    3. July 6
    4. Aug 3

    1. Sept 7
    2. Oct 5
    3. Nov 2
    4. Dec 7
19. First time CPR student?*

    1. Yes
    2. No
20. Reason for Course*
22. Corporate Group
    Are you taking this course as an individual or part of a corporate group? If in a group, please identify the group.
24. Payment Policy

    There is a minimum requirement for the number of course attendees. If this minimum requirement is not met, the course will be canceled for that evening. If canceled, a refund will be issued and applied to the account/card issued within five (5) business days. Attendees will receive a call only if the class is canceled; we do NOT call attendees to confirm registration.

    Credit card payment will be processed at the time it is submitted. Please note: If course registration is within two (2) days of the class, please contact the fire department directly for space availability at (630) 671-2841.

26. Payment Instructions
    Paying by credit card: hit Submit and follow directions on the confirmation page to pay the $45 course fee by credit card. Convenience charges apply to online credit card payments.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

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