Course Registration information

Location or Course
First Name: {field:firstname}
Last Name: {field:lastname}
Email: {field:email}
Phone: {field:phone}







You have agreed to the following



Course Expectations and Liability Waiver


To successfully complete this course

·    Participate in all practical skills, class discussions and watch and pay attention to all
course videos

Health and Safety

 There are risks and dangers inherent in participating in any emergency care course.

The risks include, but are not limited to injuries during skill practice and the possibility of acquiring communicable diseases.



Reasonable precautions to safeguard the participants health and
safety du­ring training include:

Please let the instructor know if you have any physical limitations, please do not put yourself in a position that may cause injury to yourself


Please let the instructor know if you have any physical limitations, please do not put yourself in a position that may cause injury to yourself


that have a Contagious illness should notify the instructor so

that the appropriate precautions can be taken.

·       Please watch for trip hazards

·       No Smoking, Vaping, Smokeless tobacco or alcohol
during class

Students will be provided with a
Disposable Non-Latex Gloves. Students shall use gloves and barriers shied
during practice with the manikins

Liability Waiver

 Knowingly I assume
all risks inherent with this class and hereby voluntarily release and hold
harmless EMS Training Resources,


ASHI, each of their officers, agents, employees,
and volunteers harmless from liability or

costs from injury associated with or arising
from my participation in this class including from negligence


I understand and Agree
that this release applies to personal injury, including from death,

and property damage that
I may suffer


I have read and understand this agreement: {field:covid_policy_1609725597304}

COVID – 19

·       Students should practice social distancing and
wear face coverings asper state ordinance and facility protocol

·       Students should feel free to disinfect the
manikins after reach student use, with the provided disinfectant.

·       Students will use gloves with all manikin practice,

 Ø  Students should perform hand hygiene, at regular intervals

Ø  DO not preform Mouth to Mouth on the manikins

I have Read and understand the following


 COVID-19 Questionnaire

Have you experienced any of the following symptoms in the past 48 hours

• fever or chills

• cough 

• shortness of breath or
difficulty breathing 

• fatigue 

• muscle or body aches

• headache 

• new loss of taste or smell 

• sore throat 

• congestion or runny nose

• nausea or vomiting

• diarrhea

Answer: {field:covid1}


Within the past 14 days,
have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: Anyone who is known to have laboratory-confirmed


Anyone who has any symptoms consistent with COVID-19?


Answer {field:covid2}


Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with  COVID-19?


Answer {field:covid3}


Are you currently
waiting on the results of a COVID-19 test?


Answer: {field:covid4}



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