Course Number____________
Enter date _____________
Eastern New Mexico University-Roswell, EMS Education Program
American Heart Association-Community Training Center-CLASS ROSTER-Ver. 2006.2
Course Roster General Public
On-line Renewal
1.
Type of Course (Please check only what you teach)

C P R for Friends and Family*

Family and Friends First Aid for Children*

HS Pediatric First Aid
Name of Assisting Instructor(s)
and Number
HS HeartSaver CPR
New
2
4
10.
Comments: (Use additional pages if necessary)
_____________________________________________________
_____________________________________________________
_____________________________________________________
11.
Fees:
HeartSaver/AED
_____________________ X $6.00 = $_________________
(Number of students)
(Total Fees)
Adult/child CPR with mask

Heartsaver CPR in Schools
New
Renewal

Heartsaver First aid
New
Renewal
Adult/Child CPR with mask
Adult/Child AED
Infant CPR with mask
2.
3.
4.
5.
6.
7.
8.
Course Begin Date: ____
Time:__ ___________
Course End Date: ______________ Time:____________
Number of Students: _________________
Number Completed: __________________
Site Location:
Site complete Address:________________________________
Lead Instructor: _____ _________________
Number__________________________
(If different from lead instructor)
Assisting Instructors
and Number
3
Renewal
HS HeartSaver AED
New
Renewal
Adult/child CPR with mask and choking
Adult/Child AED
Infant CPR with mask
Name of Assisting Instructor(s
1.
Eye injuries, Fever, Snake and poisonous spider, tick and
marine animal bites, scorpion stings, and suspected abuse

Date Received: ______________ By: ____
Date Cards Sent: ________________ By: ____
12.
Equipment Numbers : _____________________________
12-a Equipment cleaned by: ____________________________
13.
Method of Payment: Check or MO: #_________________
PO#______________________(Attached PO)
Credit Card: CC#__________________________V-code______
Type of card_____________ Expiration date:__________
Name on card____________________________________
14.
Evaluation completed and included:__________
15.
Classes schedule included (ACLS and PALS only): __________
FOR FRIENDS AND FAMILY there is no charge for cards if roster received with in 30 days of
the class. After that there will be a $10.00 fee for processing the roster.
If you are lead instructor it is not necessary to list yourself as assistant instructor.
Non ENMU-R, CTC Instructor Please Attach Copy of card.
Rosters received 10 days after the course will have a late roster fee of $10.00 for every 10 days
Late.
This excludes Training Sites.
FOR ALL NON-ENMU-R TC INSTRUCTORS ENCLOSED A COPY OF THEIR INSTRUCTOR CARD AND NAME OF CTC
Mail to: ENMU-R, TC, P.O. Box 6000, Roswell, New Mexico 88202-6000.. Office (505) 624-7249 email ctc@roswell.enmu.edu
Eastern New Mexico University-Roswell, EMS Education Program
American Heart Association- Training Center
Course Number____________________
Participant List (PLEASE PRINT CLEARLY-MUST BE COMPLETE) * Please remember that there are no written test for ANY HS course. Please
use the work sheets in the student manuals.*
First Name, Middle, Last Name,
Address
City/State/Zip
New
/Renewal
Pass all
Course
Instructor
Skill and Completion Potential+
Cases*
Yes/No**
Yes/No
Yes/No
Remediation
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
I verify that this information is accurate and truthful, and that it may be verified. This course was taught in accord with the guidelines of the American Heart Association.
Signature of Instructor ____________________________________________
Date: _____________________________________
FOR ALL NON-ENMU-R TC INSTRUCTORS ENCLOSED A COPY OF THEIR INSTRUCTOR CARD AND NAME OF CTC
Mail to: ENMU-R, TC, P.O. Box 6000, Roswell, New Mexico 88202-6000.. Office (505) 624-7249 email ctc@roswell.enmu.edu