CPR Registration

Course Information
Course Title*
Location
Course Begin Date
MM slash DD slash YYYY
Course Instructor*
Student Information
Student Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Home Phone Number
Work Phone Number
County
Village, Township, or City
- Village
- Township
- City
Village, Township, or City
Employer
Select One
- Full-Time
- Part-Time
Date of Birth
MM slash DD slash YYYY
Date of High School Graduation
MM slash DD slash YYYY
Most Recent High School Attended
Highest Grade Completed
Sex (Check One)
- Male
- Female
Race / Ethnicity - Optional
The following questions are confidential. Your responses will help the technical college evaluate recruitment and retention practives and will not affect admission to the class. Please respond to both questions.
Are you Hispanic or Latino?
- Yes
- No
(That is, a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or orgin, regardless of race)?
Select any other group or groups that apply to you.
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
(Check all that apply).

Course Information