EDCOR
830 Kipling Street Suite 101
Lakewood, CO 80215
Phone: 303-997-8695
Fax: 303- 993-4378
Website:
www.edcor.net
Lead Instructor:
AHA Instructor Number (required)
Instructor Phone #:
Instructor Email:
Training Site (if name is different than Lead
Expiration Date:
Address:
City
State
Zip
Address:
City
State
Zip
Instructor)
If different from above, send cards to:
Name:
Payment info:
Check Enclosed
(Make payable to EdCor, LLC)
Cash
Credit Card (from www.EdCor.net website “Pay Invoice”) Name on card (required)_________________________________
Card on file
 Permission to use card on file
Last 4 digits of card _____________
Charge facility : Point of contact name: ________________________________
Email Address of contact:________________________________
Rental Form submitted
Address: ___________________________________________________
City_________________ State__________________Zip_____________
 N/A  Yes
Date of Course:
Type of Program: (Please circle or put an X in front or highlight the course completed)
HEARTSAVER
HEARTSAVER PEDIATRIC
(Please check all that apply to class)
(Please check all that apply to class)





First Aid
CPR/AED
Child CPR/AED
Infant CPR
Written Test
 First Aid Skills Check off
 CPR Skills Check off
 FA/CPR/AED Skills Checkoff






First Aid
CPR/AED
Adult CPR/AED
Infant CPR
Written Test
Asthma Care Video
 First Aid/CPR/AED Skills Check off
HEALTH CARE PROVIDER
 BLS
 BLS skills checkoff
OTHER
 BLS Instructor
 Heartsaver Instructor
 Heartsaver Bloodborne Pathogens
 CPR for Schools
 Friends and Family
EDCOR
830 Kipling Street Suite 101
Lakewood, CO 80215
Phone: 303-997-8695
Fax: 303- 993-4378
Website:
www.edcor.net
The course for which you are enrolled may include physical strain, possibility for cross infection, and emotional stress. CPR is very strenuous both in practicing on the
manikin and performing CPR on a cardiac arrest victim. If you have any medical conditions or cardiovascular disease history that may be aggravated by this course, please
consult your physician as to whether you should participate in a CPR course. If you have any reservations about your ability to perform CPR on a cardiac arrest victim, you
may want to reconsider taking this course. If you have recently had any infectious disease, including upper respiratory infection or open sores on your mouth and/or on
hands, it is imperative to defer manikin practice. The AHA and its TCs are not certifying agencies. The AHA and its TCs are not responsible for the level of classes taught to
participants.
By filling in my name by hand, initialing by my typed name below I have acknowledged that I have read all the above statements and absolve the American Heart
Association, its TCs, and instructors from any liability associated herewith. I do not currently have any infectious disease.
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Email Address
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EDCOR
830 Kipling Street Suite 101
Lakewood, CO 80215
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Phone: 303-997-8695
Fax: 303- 993-4378
Address
Website:
www.edcor.net
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remediation
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EDCOR
830 Kipling Street Suite 101
Lakewood, CO 80215
Phone: 303-997-8695
Fax: 303- 003-4378
Website:
www.edcor.net
The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, PEARS, and PALS and has developed instructional materials for this
purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association Any fees charged for such a course,
except for a portion of fees needed for AHA course material, do not represent income to the Association.
Completed Course Roster must be submitted to EdCor within 14 days of the class. For Students who have not yet met course completion requirements, a copy of their
written examination answer sheet and skills performance sheet is attached to the roster. For onine courses copy of the on-line certificate CPR Critical Skills Testing
Check List for BLS Provider must be available by the Training Site or Instructor upon request at any time or sent to EdCor within 30 days of the course.
I, ______________________________________ (Course Director Signature) verify that I have followed the AHA requirements in presentation and testing for this class
and have used the AHA course materials. I have included the roster, evaluations or summary of evaluations, and required written test answer sheet and skills
performance sheet for any student that has not yet met AHA completion requirements for the Training Site and Training Center files.
Date:___________________
(Valid Signature is accepted when full name is typed in above)
Additional Instructors for this course:
Name: _______________________________________ Instructor TC ____________________
Instructor card Expiration Date: ________________
Name: _______________________________________ Instructor TC ____________________
Instructor card Expiration Date: ________________
Name: _______________________________________ Instructor TC ____________________
Instructor card Expiration Date: ________________
EDCOR
830 Kipling Street Suite 101
Lakewood, CO 80215
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Name
Phone: 303-997-8695
Fax: 303- 003-4378
Address
Website:
www.edcor.net
Email Address
Exam
Score
Status
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remediation
Not yet completed
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remediation
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