Pediatric Education for Prehospital Professionals: PEPP Verification Request

Pediatric Education for Prehospital Professionals: PEPP Verification Request
Please fill out this form if you need to verify a PEPP Providers status. We will respond within 3 business days.

Due to the American Academy of Pediatrics privacy policy, we are unable to release any records unless we have a signed consent for release of information on file from the individual.
Requestor's Name (REQUIRED)*

First NameLast Name
Requestor's Email Address (REQUIRED)*
example@example.com
Requestor’s Company/Institution (REQUIRED)*
Name of the individual you are requesting verification on (REQUIRED)*

First NameLast Name
Any alternate name for this individual (if applicable)

First NameLast Name
Email of the individual you are requesting verification on (REQUIRED)*
example@example.com
Any other email address for this individual (if applicable)
example@example.com
Please provide the name of the PEPP Course Coordinator whom the student had taken the PEPP course with.

First NameLast Name
Please provide the Date of the Course

MonthDayYear
Date
Please provide a signed consent form from the individual as a pdf (REQUIRED)*

Cancelof
If you have a form that you would like us to use, please upload it here as a pdf

Cancelof
If you do not have a form, please enter the information that you would like us to provide
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