Course Record

Course Record

MS Word Version Page ___ of ___

INSTRUCTOR / Melinda A. Clare / SPONSORING RED CROSS UNIT / Greater Los Angeles
(last name) / (first0 / (middle)
ADDRESS / 3809 Canehill Avenue / DATE COURSE STARTED / 3/12/2005 / DATE COURSE ENDED / 3/13/2005
TRAINING SITE INFORMATION (name of school, worksite, community organization, or Red Cross unit)
(street)
Long Beach, CA 90808 / NAME / Cabrillo Beach Youth Waterfront Sports Center (CBYWSC)
(city) / (state) / (zip)
PHONE / ( / 562 / ) / 421-8887 / STREET / 3000 Shoshonean Road
UNIT OF AUTHORIZATION / Long Beach, Greater Los Angeles / CITY, STATE, ZIP / San Pedro, CA 90732
(name of chapter/station/state/national headquarters unit)
ADDRESS / COURSE NAME / CPR for the Professional Rescuer
(city) / (state) / (zip)
Please check status for this training. / If third party is checked, indicate name of authorized provider. / COURSE CODE / 3214
RED CROSS VOLUNTEER RED CROSS PAID STAFF THIRD PARTY: / CBYWSC/Melinda Clare / TOTAL INDIVIDUALS ENROLLED IN THE COURSE / 10
CO-INSTRUCTOR / John M. Clare / COMPONENT INFORMATION
(last name) / (first0 / (middle) / COMPONENT NAME / CODE / HOURS / NUMBER ENROLLED / NUMBER PASSED / NUMBER AUDIT/INC.
ADDRESS / 3809 Canehill Avenue / O2 Admin / 3262 / 3 / 10 / 10 / 0
(street)
Long Beach, CA 90808 / PDTC / 3220 / 2 / 10 / 10 / 0
(city) / (state) / (zip)
PHONE / ( / 562 / ) / 421-8887 / First Aid / 3240 / 4 / 10 / 10 / 0
UNIT OF AUTHORIZATION / Long Beach / CPR Pro / 3214 / 4 / 10 / 10 / 0
(name of chapter/station/state/national headquarters unit)
ADDRESS
(city) / (state) / (zip)
Please check status for this training.
RED CROSS VOLUNTEER RED CROSS PAID STAFF THIRD PARTY / TOTAL HOURS / 13
Check here if address for either the instructor or co-instructor is new.
COMMENTS / ETHNIC ORIGIN INFORMATION / SEX
[Enter comments here] / WHITE / BLACK OR AFRICAN AMERICAN / MALE / 6
HISPANIC OR LATINO / AMERICAN INDIAN/ALASKA NATIVE / FEMALE / 4
ASIAN / NATIVE HAWAIIAN OR PACIFIC ISLANDER / DID NOT REPORT
Names of other co-instructors, assisting aides, instructor’s guests / PEASE CHECK ONE: / ROLE / UNIT OF AUTHORIZATION / HOURS INVOLVED / COURSE DEMOGRAPHICS
FOR HIV/AIDS EDUCATION SESSIONS ONLY
VOL. / PD. / THIRD PARTY / COURSE LOCATION (Check box that best describes the setting in which training was conducted.)
(Check one) YOUTH: SCHOOL K-12 COLLEGE/UNIVERSITY OTHER
(Check one) ADULTS: COMMUNITY WORKPLACE
CERTIFCATES (Check one): Instructor will pick up certificates. Send certificates to instructor. Send certificates to authorized provider. Certificates issued on site. Not applicable Other
I certify that this training session has been conducted in accordance with the requirements and procedures of the American Red Cross. Note: All co-instructors must sign this form if named above.
INSTRUCTOR’S SIGNATURE CO-INSTRUCTOR’S SIGNATURE
OFFICE USE ONLY
HOW PROGRAM WAS DELIVERED: FULL-SERVICE CONTRACT COMMUNITY AUTHORIZED PROVIDER / DATE RECEIVED / DATE CERTIFICATES ISSUED / DATE RECORDED / INITIALS OF PERSON ENTERING / RECORDING DATA / CHERS ID
TOTAL FEES COLLECTED / RED CROSS BRANCH

SPONSORING RED CROSS UNIT’S RECORD PLEASE SUBMIT FORM 6418AR WITH THIS FORM Facsimile of American Red Cross Form 6418R (Rev. 7-00)

Course Record Addendum

This form MUST be completed with the Course Record (Form 6418R) MS Word Version Page ___ of ___

COURSE NAME AND CODE / CPR Pro and First Aid / FOR DISASTER COURSES ONLY
SPONSORING RED CROSS UNIT
NAME OF INSTRUCTOR / Melinda A. Clare / CITY AND STATE WHERE COURSE WAS HELD
NAME OF CO-INSTRUCTOR / John Clare / SIGNATURE OF INSTRUCTOR
DATE COURSE BEGAN / 3/12/2005 / DATE COURSE ENDED / 3/13/2005 / SIGNATURE OF CO-INSTRUCTOR
COMPONENTS / 3262 / 3220 / 3240 / 3214 / NAME / MAILING ADDRESS / PHONE / INSTRUCTOR COMMENTS / DSHR / CERTS TO ISSUE (UNIT USE)
ENROLLED / LAST / Alfaro / STREET / 861 West 42nd Place #2 / ( 213)
GRADE / P / P / P / P / FIRST / Jose / CITY, STATE, ZIP / Los Angeles, CA 90037 / 232-6080
ENROLLED / LAST / Saralegui / STREET / 12131 Alpine Avenue / ( 310)
GRADE / P / P / P / P / FIRST / Erick / CITY, STATE, ZIP / Lynwood, CA 90262 / 762-2025
ENROLLED / LAST / Peterson / STREET / 1715 West 259th #3 / ( 310)
GRADE / P / P / P / P / FIRST / Ryan / CITY, STATE, ZIP / Lomita, CA 90717 / 539-8714
ENROLLED / LAST / Machuca / STREET / 12135 Alpine Avenue / ( 310)
GRADE / P / P / P / P / FIRST / Nicholas / CITY, STATE, ZIP / Lynwood, CA 90262 / 762-2160
ENROLLED / LAST / Machuca / STREET / 12135 Alpine Avenue / ( 310)
GRADE / P / P / P / P / FIRST / Jose / CITY, STATE, ZIP / Lynwood, CA 90262 / 762-2160
ENROLLED / LAST / Monraz / STREET / 353 West 11th Street #1 / ( 310)
GRADE / P / P / P / P / FIRST / Becky / CITY, STATE, ZIP / San Pedro, CA 90731 / 833-5637
ENROLLED / LAST / Sanchez / STREET / 207 West 2nd Street / (310 )
GRADE / P / P / P / P / FIRST / Evelyn / CITY, STATE, ZIP / San Pedro, CA 90731 / 832-5775
ENROLLED / LAST / Granados / STREET / 1037 West 111th Street / ( 323)
GRADE / P / P / P / P / FIRST / Ana / CITY, STATE, ZIP / Los Angeles, CA 90044 / 756-3789
ENROLLED / LAST / Sanders / STREET / 3000 Shoshonean Road / ( 310)
GRADE / P / P / P / P / FIRST / D'Auria / CITY, STATE, ZIP / San Pedro, CA 90731 / 833-9972
ENROLLED / LAST / Granados / STREET / 1037 West 111th Street / ( 323)
GRADE / P / P / P / P / FIRST / Oscar / CITY, STATE, ZIP / Los Angeles, CA 90044 / 756-3789
ENROLLED / LAST / STREET / ( )
GRADE / FIRST / CITY, STATE, ZIP
10 / 10 / 10 / 10 / TOTAL ENROLLED (Add each column) / For information on components codes and which certificate(s) each participant receives, please contact your local unit or refer to the course component chart.
10 / 10 / 10 / 10 / TOTAL PASSED (Add each column)

SPONSORING RED CROSS UNIT’S RECORD American Red Cross Form 6418AR (Rev. 6-97)