PCSI's CPR & FIRST AID/AED PRE-REGISTRATION FORM

CPR, First Aid & AED Certification Registration Form

Please fill in your information and answer the questions below to determine eligibility.
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
Address*

Street Address

Apt/Unit

CityState / Province

Postal / Zip Code
**Many of our programs and services are available to City of Pittsburgh residents; however, you may still qualify through other PCSI funding sources. Please complete the eligibility questions below:
YesNo
Review the Federal Poverty Income Guidelines (FPIG) chart and then answer the income questions that follow.
How many people live in your household?*
What is your total monthly household income before taxes?*
Include income from all household members
YesNo
YesNo

Thank you for completing the PCSI Eligibility Questionnaire. Based on the information provided, your household income is above the 200% eligibility guidelines for our program.

You may still have other options for support. Please visit our website www.pghcsi.org or contact our front desk at 412‑904‑4700 to explore additional resources or alternative services that may be available to you. We’re here to help.

Thank you for completing the PCSI Eligibility Questionnaire. Based on the information provided, your current address is outside the City of Pittsburgh, which does not meet the residency requirement for this program.

You may still have other options for support. Please visit our website at www.pghcsi.org or contact our front desk at 412‑904‑4700 to explore additional resources or alternative services that may be available to you. We’re here to help.

Thank you for registering for PCSI’s CPR, First Aid & AED Class. A staff member will reach out shortly to confirm your registration.

Proof of ID*

Cancelof
Proof of Residency*

Cancelof
Proof of Income (a copy of your Paystubs, SSI Income Letter, Unemployment Compensation Letter, Pension Letter...*

Cancelof
NON-INCOME AFFIDAVIT

I DO HEARBY SWEAR AND AFFIRM THAT I DO NOT HAVE ANY SOURCE OF INCOME. THIS INCLUDES BUT IS NOT LIMITED TO INCOME FROM ANY OF THE FOLLOWING:

1. Wages, Public Assistance (ADC, GR etc.) Social Security, SSI etc.;

2. Child Support, Alimony or regular monetary gifts from family, friends, etc.;3. Assets (homes, stocks, etc. may be inherited property);

4. Interest income from savings, checking, Christmas Club and other bank accounts, IRA’s, Certificates of Deposit, Money Market Funds, Credit Unions, etc.;

5. U.S. Savings Bonds, stocks or bonds of any kind;

6. Pensions, annuities retirement funds, etc. (this includes benefits you may receive from being a beneficiary of a life insurance or retirement plan;

7. Real Estate Property, Earned Income Tax Credit, etc.;8. ANY OTHER INCOME (includes tips, property sold, babysitting etc.)
Non-Income Affidavit Signature*

Clear
Self-Declaration of Homelessness
I First Name* Last Name* certify that I meet the definition of “homeless” or a “homeless individual” because I fall under one of the following criteria:
- An individual who is living in a place not meant for human habitation, in an emergency shelter, in transition housing, or exiting an institution where I temporarily resided for up to 90 days and in a shelter or place not meant for habitation immediately prior to entering that institution.
- An individual who has lost their primary nighttime residence, which may include a motel, hotel, or a doubled-up situation, within 14 days and lack resources or support networks to remain in housing.
- An individual with a family with children or unaccompanied youth who are unstably housed and likely to remain in that state. Families with children or unaccompanied youth who have not had a lease or ownership interest in a housing unit in the last 60 or more days, have moved two or more times in the last 60 days, and who are likely to continue to be unstably housed because of a disability or other barriers to employment.
Signature*
PARTICIPATION AGREEMENT:

Pittsburgh Community Services, Incorporated (PCSI) is dedicated to empowering individuals by providing opportunities for personal and professional growth. By signing this agreement, you acknowledge your understanding of PCSI’s program requirements and agree to:

(1) Actively participate in all required PCSI services,

(2) Submit all requested documentation in a timely manner,

(3) Follow all PCSI conduct policies as posted or communicated to you.
Participation Agreement Signature:*

Clear
GRIEVANCE PROCEDURE:

PCSI wants all of our customers to be satisfied with the programs we deliver and services we provide. If for some reason a customer is not satisfied with a program or service, that customer may submit a complaint in writing to PCSI’s Executive Director. Any complaint should detail the customer’s concerns, including information about the customer; details of the complaint; and any additional information that may be useful to the review. The Executive Director will review the complaint, discuss it with the customer, and discuss it with appropriate staff members. The Executive Director will make every attempt to resolve the situation fairly and quickly. If PCSI is not the appropriate agency to support a customer’s need, the customer will be directed to external resources.
Grievance Procedure Signature:*

Clear
*Optional* PHOTOGRAPHIC AND VIDEO RELEASE:

By signing below, I hereby give permission to PCSI to capture and use a photographic and or video like of myself for purposes related to program advertisement, news copy, web site photos, agency reporting, and recruiting of participants eligible for the services offered by PCSI, or authorized by PCSI for similar purposes within their domain and under their complete control.

My image(s)may not be used for commercial gain without my specific written consent. My image(s) and or likeness may be used in and on program brochures and/or advertisements designed to attract capital investment in PCSI programs and projects, or to win funding from contributors, donors and/or other funders. My permission may be revoked at any time by giving written notice to the agency’s Executive Director.
Photographic and Video Release Signature:

Clear
Should be Empty:

CPR, First Aid & AED Certification Registration Form

PCSI Intake

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Household Member 7

Household Member 8

Self-Declaration of Homelessness