CPR STUDENT APPLICATION
Visionary Health Career Training Institute LLC
Thank you for your expressed interest in Visionary Health Career Training Institute LLC. Fill out the form below.
CPR Application Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select Your Program
The V Offers:
*
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( X )
INITIAL BLS (BASIC LIFE SUPPORT) FEE
2.5-3 hours
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
RENEWAL BLS (BASIC LIFE SUPPORT) FEE
2 hours
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
HEARTSAVER FIRST AID CPR/AED
Duration varies
$
80.00
Quantity
1
2
3
4
5
6
7
8
9
10
FRIENDS & FAMILY (NO CERTIFICATE)
1.5 hours
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
BABYSITTING HEARTSAVER PEDIATRIC
2 hours
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Payment Options & Authorization
Check the box to acknowledge:
Payment will be processed based on your chosen payment option above. You will be responsible for the immediate payment of the total amount.
Disclaimer and Signature
If this application leads to acceptance to Visionary Health Career Training Institute, LLC, I understand that false or misleading information in my application may result in dismissal from the program.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.
Signature
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-
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