CPR & First Aid Registration Form

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By Telephone: (530) 272-3265, 9:00am - 4:00pm, Reservations, Credit Card Payment.
By Fax: (530) 272-5212, 24-Hours, Fax this form, Credit Card only 
By Mail: Mail this form with payment to: 
Health & Safety Dept., American Red Cross, P.O. Box 250, Grass Valley, CA 95945
In Person: 144 Hughes Road, Grass Valley, Suite G , 9:00am - 4:00pm


Name___________________________________________________________________________________ 

Home Phone:________________________________ Work Phone: _________________________________

Address_________________________________________________________________________________

City, State, Zip___________________________________________________________________________

Selection: Give 2 choices. Classes fill early. First come, first served. It is suggested that you call to verify class availability and reservations recommended.

Course Name:___________________________________________________________________________

1st Choice Date ___________________________________________Class No._____________________

2nd Choice Date __________________________________________Class No.______________________

__ I am enclosing the full course fee ...................................................................Amount $ _________


__ Total Amount Enclosed..................................................................................Amount $ _________


Payment (Must be received before class date. Confirmation will be made within 48 hours)

Paid By: Check____ VISA____ MasterCard____ 

Card No.____________________________________________________ Exp Date:__________________

Cardholder's Name_________________________Signature_________________________Date_________

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