Register Your Bleeding Control Class
Please provide all required details to register your class with us
Instructor
*
First Name
Last Name
Organization Name
*
Contact Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Address of the Class
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Class
*
-
Month
-
Day
Year
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Location to Pick up Kits
*
Please Select
West Bend via Tom Thrash
Waukesha Memorial via Michelle Hackett
Aurora St Luke's via Wendy Golonski
Ascension St Joseph's via Keli Anderson
Froedtert Milwaukee via Ginger Knapp
Fond du Lac via Kelly Faymoville
Is this class posted on the ACS website https://cms.bleedingcontrol.org/class/search
*
Please Select
Yes
No
# of people in the class
*
Would you like to have a free STB kit to use as a door prize at your class. By asking for a free STB kit you may be responsible to pick up from one of our storage locations
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Product Name
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Free
$
Free
Quantity
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2
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