Heartsaver© Course Roster
American Heart Association
Course Information
Type a question
*
Heart Saver CPR AED
Heartsaverr First Aid CPR AED
Heartsaver First Aid
Heartsaver Pediatric First Aid CPR AED
Heartsaver for K-12 Schools
Heartsaver Instructor
Training Center
Eyes On Health CPR
Training Center ID#
GA50566
Lead Instructor
*
First Name
Last Name
Lead Instructor ID
*
Card Expiration Date
*
-
Month
-
Day
Year
Date
Training Center
*
Training Center ID
*
Training Site Name (if applicable)
Address
City State ZIP
Course Location
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Assisting Instructors
Attach copy of instructor aligned with a TC other than the primary TC
1. Instructor Name
First Name
Last Name
Instructor ID
Card Exp. Date
-
Month
-
Day
Year
Date
2. Instructor Name
First Name
Last Name
Instructor ID
Card Exp. Date
-
Month
-
Day
Year
Date
3. Instructor Name
First Name
Last Name
Instructor ID
Card Exp. Date
-
Month
-
Day
Year
Date
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Course State Date
*
-
Month
-
Day
Year
Date
Course Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Course End Date
*
-
Month
-
Day
Year
Date
Course End Time
*
Hour Minutes
AM
PM
AM/PM Option
Total Hours of Instruction
*
make sure the hours are correct!
No. of Cards Issued
*
Student-Manikin Ratio
Please Select
3:1
2:1
1:1
Issue Date of Cards
*
-
Month
-
Day
Year
Date
Heading
I verify that this information is accurate and truthful and that is may be confirmed. This course was taught in accordance with AHA guidelines.
Signature
Date
-
Month
-
Day
Year
Date
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Course Participants
verify that this information is accurate and truthful and that it may be confirmed. This course was taught in accordance with AHA guidelines.
1. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Complete/ Incomplete
Please Select
complete
incomplete
2. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
3. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
4. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
5. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
6. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
STOP!
A supporting instructor is required to filling out 7-10 to adhere to AHA's ratios. Fill out another roster if there is not a supporting instructor. ONLY FILL IF THERE IS AN ASSISTING INSTRUCTOR.
7. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
8. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
9. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
complete
incomplete
10. Participant Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
complete/incomplete
Please Select
Complete
Incomplete
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Course Certificate Upload
If course participants completed part 1 online, please upload certificate of completion. Upload multiple certificates as zip file.
File Upload
Browse Files
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