Application Form for Course
For the Standard First Aid and CPR-C with AED course.
First Name
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Last Name
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Date of Birth
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Gender
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Street Address
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Apartment/Unit #
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City
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Province
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Postal Code
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Telephone
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Alternate Telephone
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Email Address
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Emergency Contact Name
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Relationship to participant
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Contact Number
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Alternate Number
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Is there any medical or special needs information that you would like us to know?
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Course Date
Method of Payment
Release of Liability, Waiver of Claims, Assumption of Risks Agreement (Please Read Carefully!)
I recognize that risk of injury or potential health risk may be involved in participation in the above‐named program/activity. I hereby willingly assume such risk of injury or health risk for myself or for the above‐ named person(s) for whom I am in law responsible and assume full responsibility before, during and after my/their participation in the program/activity and any associated or related activities In consideration of the acceptance of my application and the permission to participate in the program/activity, I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE, ANDFOREVER DISCHARGE the Emergency Medical Response Group, all other organizations, associations, companies associated with any of the programs offered by the Emergency Medical Response Group, and all their respective representatives OF AND FROM ALL claims, demands, damages costs and actions whatsoever and however caused, arising or to arise by reason of my participation in the program or any of its associated activities
Initials
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