CPR Reimbursement Form
Submit your reimbursement request here
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Organization
*
Organization EIN #
*
Organization Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date you attended the CPR training
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Receipt
*
Browse Files
Drag and drop files here
Choose a file
This receipt should show you paid for the class
Cancel
of
Upload CPR Certificate
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you hear about the CPR Reimbursement Program?
*
Brookings Area United Way Website
My Organization
Event
Word-of-Mouth
Other
Submit
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