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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email Address*
16. Heartsaver Health Care Provider BLS Course Date*

    Please choose a course date:

    1. Nov 16, 2023
    2. Dec 21, 2023
    3. Jan 18
    4. Feb 15
    5. Mar 21

    1. Apr 18
    2. May 16
    3. June 20
    4. July 18
    5. Aug 15

    1. Sept 19
    2. Oct 17
    3. Nov 21
    4. Dec 19
18. Reason for Course*
19. Corporate Group
    Are you taking this course as an individual or part of a corporate group? If in a group, please identify the group.
21. 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. Each attendee will be notified by phone with a reminder, and/or update to the status of the course. 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.
23. Payment Instructions
    Paying by credit card: hit Submit and follow directions on the confirmation page to pay the $60 course fee by credit card. Convenience charges apply to online credit card payments.
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

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