Heartsaver
®
Course Roster
Emergency Cardiovascular Care Programs
Course Information
Heartsaver CPR AED
☐ Child CPR AED ☐ Infant CPR ☐ Exam
Heartsaver First Aid CPR AED
☐ Child CPR AED ☐ Infant CPR ☐ Exam
Heartsaver First Aid
☐ Exam
Heartsaver Pediatric First Aid CPR AED
☐ Adult CPR ☐ Exam
Heartsaver for K-12 Schools
☐ Child CPR AED ☐ Infant CPR ☐ First Aid ☐ Exam
Heartsaver Instructor
Lead Instructor __________________________________________
Lead Instructor ID#
Card Expiration Date
Training Center
Training Center ID#
Training Site Name (if applicable)
Address
City, State ZIP
Course Location
Course Start Date/Time
No. of Cards Issued
Course End Date/Time
Student-Manikin Ratio
Total Hours of Instruction
Issue Date of Cards
Assisting Instructor (Attach copy of instructor aligned with a TC other than the primary TC)
Name and Instructor ID# Card Exp. Date
Name and Instructor ID# Card Exp. Date
1. 5.
2. 6.
3. 7.
4. 8.
I verify that this information is accurate and truthful and that it may be conrmed. This course was taught in accordance with AHA guidelines.
Signature of Lead Instructor Date
KJ1216 HS R4/18 © 2018 American Heart Association
