First Aid Course Participant FormParticipant InfoYour Name* First Last Your Age* 14 and under 15-24 25-34 35-44 45-54 55 and overGenderStreet Address*City*Postal Code*Phone*Email* I understand that my e-certification and a recertification email (in 3 years) will be sent to my email.* YesGet a recertification reminder email in about 3 years. We respect your privacy and will not rent or sell your information. You can be removed from the list at any time.How did you hear about Right Reaction?* Red Cross website Workplace Google search Business card Flyer Direct mail Referral OtherReferral's NameIf other, please describe:Course InfoCourse Start Date MM slash DD slash YYYY Course I'm Taking* Standard First Aid & CPR/AED Blended (50% Online)(SFA) Standard FIrst Aid & CPR/AED Recert (SFA-r) Standard First Aid & CPR/AED Traditional (100% In-Class)(SFA) Emergency FIrst Aid & CPR/AED (EFA) CPR/AED BLSIf other, please describe:I'm Interested In: First Aid Kit Car First Aid Kit Disaster Kit Swim Lessons Babysitting Course Boater Exam Pet First Aid Sport First Aid AED PurchaseClick the box and we'll email you detailsHealth PrecautionsRight Reaction is committed to safeguarding the health and safety of participants in any course. For most people, the physical activity involved in a First Aid/CPR course should not pose a threat to your health. There are a small number of people who may find the physical activities in this course strenuous.If you have any of the health conditions listed below, we recommend that you do not participate in the skills practice and demonstration involving physical activity until you have checked with your personal physician:A history of heart attack / other heart conditionsRespiratory problemsOther physical disabilitiesAre pregnantIf you are unsure if you should participate in any physical aspect of the course, please see the instructor before the course begins. Should you wish not to perform the physical skills, you cannot successfully complete the course and receive certification. Please talk to the instructor about acceptable modifications.I have read and understand the Health Precautions* YesΔ