AHA TC Affiliate Instructor Roster

*This Roster is used for An Instructor who is affiliated with

Faithful Guardian Train Center but is not an Employee of FGTC
Email: cpr@faithfulguarian.com Webisite: www.faithguardian.com

HEALTHCARE Courses HEARTSAVER Courses Friends & Family Courses Courses Information Number
Computer or Online Course ( check here ): ________ Manikins
Healthcare Provider X Adult General Public Courses
ACLS Child CPR in Schools Course Date: JAN 17,2020 Adult: 4
ACLS EP Infant AED Total Course Hours:
PALS AED Adult Start Time: 17:00 End Time: 21:00 Child: 4
Physician available for Heartsaver First Aid Child
ACLS / ACLS EP / PALS Enviromental Infant Total Participants Complete: 12 Infant: 3
Emergencies First Aid
Course Location: OMS OFFICE AED: 4

Name of Instructor(s) CTC Instructor Email Instructor Number Instructor Phone

( Print Information ) (Found on AHA Inst. Network) ( Best Contact Number )
Lead Instructor
1 Matthew W Adair FGTC www.WGACPR@YAHOO.com 4130169710 (770) 940-2902

2 FGTC

3 FGTC

4 FGTC

5 FGTC

6 FGTC

Mail Card to -Bill to: TCF / RF Contact Information ( send monitor form )
Only fill out if not same as Lead Instructor Only fill out if monitoring / mentorintg instrutors Manikins Decontaminated By:
Name: Name:
Address: Address: Matthew W. Adair
City, St Zip: Villa Rica Georgia 30180 City, St Zip: Instructor Signature
Phone# Phone#
w W. Adair