CPR Parent Kit Request - Parent Registration Form
The purpose of this form is to request a CPR Kit. A reminder that a kit should be requested for any at risk children at the time of their admission. This replaces the previous practice of faxing or emailing. Please call the Life Support Office at 617-355-2649 (x52649) or email bls@childrens.harvard.edu with any questions.
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Urgent notice: Off hours/Weekend kits 
Beginning  Wednesday March 1, 2023  The CPR bin is moving from the current location of 7S/7B. All holiday/weekend CPR kits will be available to be picked up outside the Life Support Office located in Fegan Subbasement room 0031 from the CPR bin. During office business hours Monday - Friday CPR kits will still be delivered at 11am and 2pm by request.
Please complete the form ENTIRELY and select SUBMIT at the end of the form.
Delivery times: Twice Daily on Weekdays to the requesting unit front desk
Monday - Friday 11AM and 2PM. Requests received before 11AM Monday-Friday will be delivered the same day at 11AM, any requests after 11AM will be delivered the  same day at 2PM, any requests after 2PM will be delivered the following day Tuesday-Friday at 11AM, any requests after 2PM on Friday will be delivered the following Monday at 11AM. Any requests can always be picked up from the Life Support Office located in Fegan 0031. A reminder to please call the office at X52649 to ensure that someone is there to assist you.

NO Deliveries on Weekends or Holidays:  For kits required during weekends and Holidays beginning March 1, 2023: once a request has been submitted, they are available to be picked up from the CPR box outside the Life Support Office in the Fegan basement room 0031. 

*Important Note: On this request If you choose the "picked up from weekend kit" we will assume the family received it and will not be able to provide a second kit.
 Please contact the office Mon - Fri 6am -3:30pm at ext.52649 with any question/ concerns.
Child's Last Name *
Child's First Name *
Date of Birth *
MM
/
DD
/
YYYY
Medical Record Number *
Floor/Unit Requesting Kit (Be Specific A/B if applicable) *
Diagnosis *
Kit Requested *
If you require a additional copy of the information letter in a language other than English, please list below the language preferred 
Time of Request *
Time
:
Method of Delivery *
Last Name, First Name of Requesting Individual *
Email Address of Requesting Individual *
Thank you for your cooperation. The Life Support Program Team.
RBE 2023
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