CPR/FIRST AID COURSE REIMBURSEMENT SUBMISSION
Congratulations on completing your in-person AHA Infant, Child, and Adult CPR/FIRST AID Course certified course. Please complete the following information to initiate the reimbursement process. Make sure you retain your receipt and get your certification card. A CFSA staff person will reach out to you to verify. All information listed below is needed to support reimbursement that will be mailed to your home in the form of a check. When providing the cost of your class, add the amount before taxes. Additionally, each resource parent within the same household must complete a separate reimbursement form if both took the course. Reimbursement times vary but can be expected between 2 - 4 weeks after the request is submitted. If there are any questions, please reach out to Trista Davis at trista.davis@dc.gov.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Date of Class
*
-
Month
-
Day
Year
Date
Infant, Child, and Adult CPR/First Aid Course Vendor Name
*
Site Location
*
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Total 0.0
Total Cost (No Tax)
*
Foster Parent Support Worker
Did you receive a certificate?
*
YES
No
If you did not receive a certificate, when you are you projected to receive it?
My signature affirms that the information I have provided is accurate and truthful to the best of my knowledge and belief.
*
Continue
Continue
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