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? Yes No 2. Does the group have a website that we can link too? Yes No 3. Does the group have a newsletter that we can link too? Yes No 4. Can the group provide internet, screen, and projector? Yes No 5. Can the group provide a white board for our instructor? Yes No Medical QuestionsDo you have any medical issues? Yes No Explain:Are you taking any medication? Yes No Explain:Do you have special needs or requirements? Yes No Explain:Are you taking any medication? Yes No Explain:
