Hart CPR On-Boarding Form

Hart CPR Onboarding Form

It is easy to enroll in a Hart CPR Training course. I want you to have the best experience, so please take a moment to complete our new online Hart CPR Onboarding Form. Simply fill it out, click submit, and viola! You are well on your way to becoming CPR certified! Thank you for choosing Hart CPR Training. Appreciatively, Rose Hartoonian Owner, Instructor, LVN Nurse

Step 1 of 4

Date(Required)

APPLICANT INFORMATION

**Please enter your last name exactly as you would like it to appear on your certification card.**

Name(Required)

First Middle Last Suffix

** Your certification card, course information, reminders, or registration materials will be sent to this email address.**

Email(Required)
Enter Email Confirm Email

Phone

Country Phone Number

COURSE DATE & TRAINING INFORMATION
Requested or Scheduled Course Date
Requested Course Time
Enter Date
Month
Day
Year

Enter Time

Hours

:

Minutes

AM/PM

I am Registering As: (Please select one)
Please select how you will be registering as(Required)
Individual Student
Healthcare Professional
Teacher
Daycare/Childcare Provider
School Employee
Coach
Caregiver
Parent
Business/Organization Employee
Other
Is training being provided through an employer or organization

No

Yes
Please enter the Employer or Organization's name:
LOCATION PREFERENCE
Please Make Your Selection

I am coming to the HART CPR TRAINING location

HART CPR TRAINING will be traveling to me

Training will be held at my workplace

Training will be held at a daycare or school

Training will be held at another location

Location has not been determined yet
Address
Street Address Address Line 2 City State ZIP Code

Is there anything I should know about finding or entering the location?

Gate Code

Apartment Number

Building Number

Parking Instructions

Security Entrance

Check-In Requirements

Stairs/Access Points

Other Special Instructions
Please Provide The Information Here:
Preferred Instructional Area

Living Room

Classroom

Conference Room

Office

Daycare Room

Community Room

Outdoor Area

Other

PHYSICAL & LEARNING CONSIDERATIONS
Do you have any physical or learning limitations?

No

Yes
Please list any accommodations here:

PLEASE SELECT A CPR PROGRAM
Make Your Selection...
AHA BLS – BASIC LIFE SUPPORT
HSI CPR, AED & FIRST AID
PEDIATRIC FIRST AID, CPR & AED
WILDERNESS FIRST AID & CPR
Please select your role or occupation

RN

LVN/LPN

CNA

Medical Assistant

EMT/Paramedic

Dentist/Dental Staff

Physician

Respiratory Therapist

Healthcare Student

Caregiver

Other

Are you taking BLS because your employer or school requires it?
No
Yes
Please list the name of your employer or school, here
Do you currently hold a BLS certification?
No
Yes
Expired
If Yes, when is your BLS Certificate set to expire?
Is this course needed by a particular deadline?
No
Yes
If Yes, what is your deadline to become certified?
Reason(s) you need your certification card as soon as possible for:

Employment

School/Clinical Placement

Licensing

Job Application

Renewal

Other

Which training do you need?
Adult CPR/AED
Child CPR/AED
Infant CPR
Adult/Child/Infant CPR & AED
First Aid
CPR/AED & First Aid Combination
Unsure
Why are you taking this course?

Employer Requirement

School Requirement

Personal Knowledge

Caregiver Requirement

Coaching/Sports

Workplace Safety

Other

Does your employer require a specific certification or course format?
No
Yes
Unsure
If yes, please explain:
What best describes your role?

Daycare Provider

Preschool Teacher

Teacher

Teacher Assistant

Childcare Worker

Babysitter/Nanny

Foster Parent

School Employee

Coach

Camp Staff

Parent

Other

Please provide the name of the Daycare, Preschool, School, or Organization:
Is this training required for your employment?
No
Yes
Are you completing this course for a childcare licensing requirement?
No
Yes
Unsure
Do you need both Pediatric First Aid and Pediatric CPR/AED?

Yes

CPR/AED Only

First Aid Only

Unsure
Is there a deadline by which your certification must be completed?
No
Yes
Please enter your required completion date here:
Why are you taking Wilderness First Aid/CPR?

Hiking

Camping

Outdoor Employment

Scout/Youth Organization

Coaching

Outdoor Recreation

Personal Preparedness

Workplace Requirement

Other

What types of outdoor activities do you participate in?
Do you have previous CPR or First Aid experience?
No
Yes
Are there any specific wilderness emergencies you are especially interested in learning about?
Bleeding
Fractures
Sprains
Heat Illness
Hypothermia
Snake Bites
Allergic Reactions
Hiking Emergencies
Evacuation situations
Splinting
If not listed above, please tell me what you are especially interested in learning

CHECKLIST BEFORE SUBMITTING
Please REVIEW EACH LINE ITEM before submitting:
I have reviewed my first and last name and understand that my name should be entered exactly as I want it to appear on my certification.
I have verified that my email address is correct because certification information may be sent electronically.
I understand that CPR and First Aid courses may involve hands-on skills practice.
I understand that I should notify HART CPR TRAINING before class if I need a reasonable modification for hands-on skills practice.
I understand that providing information about physical or learning considerations is voluntary and is requested only to help HART CPR TRAINING provide an appropriate learning environment.
I understand that course completion and certification may require successful participation in the skills and/or testing requirements applicable to my selected course.
Name
First Middle Last Suffix
Date
Month
Day
Year