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Please complete ALL the information below Mail form to: 1200 N.

Elm Street Attention: Lisa Dubili - Staff Education Greensboro, NC 27401

Heartsaver First Aid Course Registration Form


INCLUDE THE FOLLOWING: Non-employee of Moses Cone Health System - send check for $60 (includes cost of textbook) Employee of Moses Cone Health System - send check for $ 10 (cost of textbook)

Please Note: All registration charges will be non-refundable


Participant Name: Position: Mental Health Technician Participant Cell Phone #: Participant (SIGNATURE): ________________________________________________ Date of Course: May 16th, 2012 Current Heartsaver First Aid manual is required for this course. Signature required on registration form verifying that the participant has purchased and will receive the current manual before the course according to AHA guidelines. I confirm that I will have access to the current version of the Heartsaver First Aid manual. Signature: _____________________________ Date: __________________________

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