Request For Program Upcoming Programs Group Request For Program Group ParticularsName of Organization:Organization Address:Region:Representative Name:Representative Phone:Email Address:Program Selection:Home Alone Requested Date(S):Babysitter Training Requested Date(S):Youth First Aid Requested Date(S):CPC Requested Date(S):HCP Requested Date(S):Emergency First Aid & CPC/AED Requested Date(S):Standard First Aid & CPC/AED Requested Date(S):Standard First Aid & CPR for Health Care Providers Requested Date(S):Pet First Aid Requested Date(S):WHMIS Requested Date(S):Safe Choice Team Member Questions:1. Can we email the registration forms to the group?YesNo2. Does the group have a website that we can link too?YesNo3. Does the group have a newsletter that we can link too?YesNo4. Can the group provide internet, screen, and projector?YesNo5. Can the group provide a white board for our instructor?YesNoMedical QuestionsDo you have any medical issues?YesNoExplain:Are you taking any medication?YesNoExplain:Do you have special needs or requirements?YesNoExplain:Are you taking any medication?YesNoExplain:
