Limen Vitalis — Student Pre-Registration & Training Profile
Complete this in 3–4 minutes to share your course choice, contact details, training background, learning preferences, and acknowledgments.
Class / Registration Context
Class or Event Name / Code
Course Requested / Assigned
*
Please Select
AHA BLS Provider
AHA HeartCode BLS Skills Session
AHA Heartsaver CPR AED
AHA Heartsaver First Aid
AHA Heartsaver First Aid CPR AED
AHA Heartsaver Pediatric First Aid CPR AED
AHA Heartsaver Bloodborne Pathogens
ACS STOP THE BLEED
LV Severe Bleeding & Tourniquet Skills
LV Opioid Overdose & Naloxone Response
LV Emergency Recognition & Initial Assessment
LV Lab / Medical Simulation
Other
Attendance Source
*
I registered myself
Sent here by my employer or organization.
An event host or organization referred me
Other
Employer / Organization / Event Host Name
Student Contact Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Email Address
*
example@example.com
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City / ZIP Code
*
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Training Background
Have you taken any related medical or safety training before?
*
Yes
No
If yes, which trainings have you completed?
CPR/AED
First Aid
BLS
STOP THE BLEED
EMT/EMS
Nursing/Healthcare
Military/Tactical Medical
Workplace Safety
Other
How long ago was your most recent related training?
Please Select
Less than 1 year
1–2 years
3–5 years
More than 5 years
Not sure
How confident are you responding to a medical emergency?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Your learning goals
What do you most want to be able to do after class?
*
Recognize when someone needs emergency help
Call 911 and communicate clearly
Perform CPR
Use an AED
Control severe bleeding
Use a tourniquet
Pack a wound
Provide basic first aid
Respond to an opioid overdose
Use naloxone
Assess an injured or ill person
Work more effectively as part of a team
Stay calmer during an emergency
Practice realistic scenarios
Understand why the skills work
Other
Is there a specific situation, skill, or question you want the instructor to address?
Main reason for taking this training
*
Work requirement
Personal preparedness
Healthcare/EMS education
Family/caregiver responsibility
Outdoor/shooting/range preparedness
School requirement
Professional development
General interest
Other
Learning preferences
Which learning methods help you most?
*
Hands-on practice
Instructor demonstration
Short explanation before practice
Understanding the science / why it works
Visual diagrams or images
Realistic scenarios
Repetition
Small-group practice
Step-by-step coaching
Group discussion / questions
Written reference materials
Preferred class pace
*
Fast and focused
Moderate / balanced
Slower with more explanation
No preference
Comfort practicing skills in front of other people
*
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
Would realistic medical simulation help your learning?
*
Yes
Maybe
No
Not sure
Optional note for the instructor about realistic injury or bleeding simulation
Accessibility / Participation
Do you need a reasonable accommodation or modification to participate?
*
Yes
No
Prefer to discuss privately
If needed, how should Limen Vitalis contact you?
Phone
Email
Training Acknowledgments / Limitations
Acknowledgment of Training Scope
*
I understand this is education and training, not a physician-patient relationship
I understand this is not individualized medical advice
Other
Externally Credentialed Course Requirements
*
I understand completion of an externally credentialed course depends on meeting the issuing organization's requirements
I understand attendance or payment alone does not guarantee a credential
Other
Limen Vitalis and External Programs
*
I understand Limen Vitalis training and LV Lab simulation are separate from AHA, ACS, NAEMT, and other outside programs unless specifically identified
Other
Training Activities May Include
*
Physical skills practice
Manikins
Simulated wounds
Moulage
Training tourniquets
Wound-packing trainers
Realistic scenarios
Other
Safety and Reporting
*
I agree to follow instructor safety directions
I will immediately report any injury
I will immediately report any equipment problem or concern
Other
Emergency Priority
*
I understand real medical emergencies take priority over training
I understand emergency services may be activated if necessary
Other
Ordinary Training Risks
*
Minor muscle soreness
Kneeling discomfort
Contact with training equipment
Emotional discomfort from realistic scenarios
Other
California Assumption of Risk / Release Acknowledgment
*
I acknowledge and assume ordinary risks of training to the extent allowed by California law
I understand this acknowledgment does not waive gross negligence, reckless misconduct, intentional misconduct, or other non-waivable rights
Other
Media and Marketing Consents
Consent to use my photo or video in training photos or footage
Yes
No
Opt in to Limen Vitalis email/newsletter updates
Yes
No
Signature
Student Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / Guardian Name
First Name
Middle Name
Last Name
Relationship to Student
Please Select
Parent
Guardian
Other
Parent / Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent / Guardian Email
example@example.com
Submit
Submit
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