CPR / AED Individual Registration Form

Name:
Address:
City:
State:
Zip Code:
Phone:
Email:
Check one:
UB Registered Student 
UB Faculty/Staff 
Community 
   
Check Course:
BLS for Healthcare Providers ($50.00) 
Offered on Monday evenings or Saturday mornings

BLS for Healthcare Providers with First Aid ($60.00) 
Offered on Monday evenings or Saturday mornings

BLS for Healthcare Providers with Pediatric First Aid ($60.00) 
Offered on Monday evenings or Saturday mornings

Heartsaver CPR & AED (Adult & Child, Infant Optional) ($50.00) 
Offered on Tuesday evenings

Heartsaver First Aid with CPR & AED  ($60.00) 
Offered on Tuesday evenings

Please enter your preferred class date:   

Will you require First Aid Training?

Payment method:

Staff intitials _____ Receipt #_________ Transmittal #______________ Date ___________

Send payment and printed registration form:
CPR / AED Training Center
130 Alumni Arena
Buffalo, NY 14260

Submitting the registration form does not automatically sign you up for the class of your choice. You will receive an email confirming date/time/location of the class to which you are assigned.