Course Roster/Participation List
Please PRINT clearly!
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Name As you would like to appear on your card |
Address |
Phone |
First Time Student |
Exam Score |
Remediation Provided/ Date Complete |
Course Complete Y/N |
Date Cards Issued |
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1. |
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Y
N |
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2. |
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Y N |
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3. |
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Y N |
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4. |
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Y N |
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5. |
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Y N |
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6. |
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Y N |
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7. |
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Y N |
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8. |
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Y N |
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9. |
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Y N |
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10. |
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Y N |
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I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA
guidelines.
Signature, Course Director or Lead Instructor:
_____________________________________________ Date:
_________________
Disclaimer:
The American Heart Association strongly promotes knowledge and
proficiency in BLS, ACLS, and PALS and has developed instructional materials
for this
purpose. Use of these materials in an educational
course does not represent course sponsorship by the American Heart
Association. Any fees charged for
such a course, except for a portion
of fees needed for AHA course material, do not represent income to the
association.