Course/Program	Date	Time	Location	Fee
Adult CPR & AED only				$30
Infant/Child CPR only				$30
First Aid only				$30
Adult/Infant & Child CPR				$41
Adult CPR & First Aid				$41
Infant/Child CPR & First Aid				$41
Adult/Infant & Child CPR & First Aid				$48
Babysitters Training				$45
Sports Safety Training				$40
Challenges				$25
CPR for Professional Rescuer				$60
Other Courses/Programs
SAVE-A-LIFE SATURDAY				$15

Any known allergies/medical conditions
_____________________________________________________________________________________
_____________________________________________________________________________________

Participant's Name(s):____________________________________________________________________

Daytime Phone:_(___)_____________________ Home Phone:_(___)____________________________
Address:_______________________________________ City:____________________ Zip:__________

Payment Enclosed: Check Money Order (Please do not send cash)
Visa___Mastercard___American Express___
Credit Card Number___________________________________Expiration Date(M/Y)_____/_________
Name on card_________________________________________

Note: Request for refunds must be received at least three working days prior to the course start date.
There is a $5.00 administative fee for refunds. No refunds are given for courses that total $15.00 or less.
*Nursing Contact Hours (Applies only to instructor-level courses and some disaster classes) $30.00 processing fee per offering.
I am a:  R.N. L.P. Processing Fee(s): __________

Mail to:
American Red Cross of Delaware County
5 W. Winter Street
Delaware, Ohio 43015 

Release of All Claims

My signature below indicates that I elect to participate in an American Red Cross Course. With my participation, I do hereby and discharge the American Red Cross, Delaware County Chapter, its assignees, agents and employees, and officials and their successors from any and all liability in the event of an accident or incident. I further certify that my physical condition will enable me to participate fully in the class.
Read Carefully. By signing this you may give up legal rights

Permission For Use

I give to the American Red Cross, its nominees, agents, and assigns, unlimited permission to use, publish and republish for purposes of advertising , trade, or any other lawful use, information about me and reproductions of my likeness (photogenic or otherwise) and my voice, whether or not related to any affiliation with the American Red Cross, with or without my name.

______ I do not give permission for the participant to be photographed.

Read Carefully. By signing this you may give up legal rights

X_________________________________________________________/_______/________
Signature of participant (if under 18 parent or gaurdian signature) date
 Please, call me! I'm intrested in volunteer opportunities!