GWRRA Indiana District
Request For MEDIC FIRST AID^® /CPR/A.E.D. Class

Please fill out and submit this form to request a MEDIC FIRST AID^® Class for your chapter. A service fee of $20.00 per person is required and must be submitted no latter than two (2) weeks prior to the scheduled class date. Please include your choice of dates for the class and fill in all contact information. You may also choose to print a blank form and complete it by hand for submission.

Please CLICK HERE for form to be submitted by postal mail:

Chapter:
Class Location:	Address: City: State: Zip:

Chapter Director Information:
Name:
Address:
City:	St.:	Zip:
Phone:	Email:

Chapter Educator Information: (or person responsible for setting up this class)
Name:
Address:
City:	St.:	Zip:
Phone:	Email:

Requested Dates:
1st Choice	2nd Choice:	3rd Choice:
Number of students expected:

MEDIC FIRST AID is a registered trademark of MEDIC FIRST AID International, Inc.

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