Basic Life Support Roster
Emergency Cardiovascular Care Programs
Course Information
*
BLS Course
BLS Renewal Course
Heartcode BLS
BLS Instructor Course
Lead Instructor
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Lead Instructor ID
*
eCards to be issued from:
*
Pease ANG Inventory
Students paying on their own from link
Unit paying on their own from link. Enter unit name or contact in the next text box.
Invoice unit. Enter unit contact information in next text box
Enter name of unit. If Coastal CPR & First Aid is invoicing the Unit, please also enter name and email address to send invoice to:
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Card Expiration Date
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Month
/
Day
Year
Date
Training Center
Training Center ID
Training Site Name (if applicable)
Address
Address
Street Address Line 2
City, State ZIP
State / Province
Postal / Zip Code
Course Location
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Course Start Date/Time
*
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Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Course End Date/Time
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Total Hours of Instruction
*
Student to manikin ratio (3:1, 2:1, or 1:1)
*
Student-Manikin Ratio
*
1:1
2:1
3:1
No. of Cards Issued
*
Issue Date of Cards
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Month
/
Day
Year
Date
Assisting Instructors
Please list any assisting instructors here. If you need more space than listed here please contact us at classes@coastalcpr.com.
1.
Name & Instructor ID #
Card Exp. Date
/
Month
/
Day
Year
Date
2.
Name & Instructor ID #
Card Exp. Date
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Month
/
Day
Year
Date
3.
Name & Instructor ID #
Card Exp. Date
/
Month
/
Day
Year
Date
4.
Name & Instructor ID #
Card Exp. Date
/
Month
/
Day
Year
Date
5.
Name & Instructor ID #
Card Exp. Date
/
Month
/
Day
Year
Date
I verify that this information is accurate and truthful and that it may be confirmed. This course was taught in accordance with AHA guidelines.
*
Signature of Lead Instructor
Date
*
/
Month
/
Day
Year
Date
Back
Next
Enter course name:
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Course Participants - Roster Upload or Enter in your student information
An uploaded roster and/or student information is required.
Upload your roster here. For Heartcode BLS skills sessions you must include all Heartcode BLS course completion certificates. If you do not upload a roster, you must enter all of your student information in the fields below.
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Also upload any other supporting documentation for your class.
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Student 1
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 2
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 3
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 4
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 5
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 6
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 7
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 8
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 9
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
Student 10
First Name
Last Name
Email
example@example.com
Mobile number
Format: 000-000-0000.
Complete/Incomplete
Complete
Needed Remediation
Remediation Provided
Enter exam score. If remediation provided, enter both exam scores.
96 or 80 / 88
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