CPR class interest form
Are you interested in holding or hosting a CPR class?
Name
*
First Name
Last Name
Is this class going to be for an individual or business?
*
Individual
Business
Both
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Are you a member of a Police/Fire/EMS agency, or do you work in healthcare?
*
Yes
No
Class Requested
*
AHA CPR/First Aid
BLS Healthcare Provider
Both
Would you prefer a weekday or weekend class?
*
Please Select
Weekday
Weekend
Doesn't matter
Would you prefer a Morning/Afternoon/Evening (reminder each class is about 4 hours give or take)
*
Please Select
Morning
Afternoon
Evening
Doesn't matter
Please enter 2-4 dates that are open on the Calendar that you would be interested in having a class.
*
Number of students.
*
Questions/Comments/Concerns?
*
Please verify that you are human
*
Submit
How will my information collected be used?
Information provided on this form will not be given to or sold to anyone, this information will be used by Ross Media LLC based out of Shinnston, WV to see if there would be any interest in CPR, First Aid, or BLS Classes. If you mark Individual on this form, Ross Media LLC will reach out to you Via E-mail to let you know about classes that will be conducted in your area. If you mark Business Ross Media LLC will reach out to you via Phone or E-mail to discuss setting up a class for your Business, Police, Fire, or EMS Agency.
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