American Red Cross

CPR/First Aid

February 16 & 17 2017

Course Description

This course is especially designed for health care professionals, public safety personnel, emergency response and first aid team members, lifeguards, EMT's and others who have a duty to respond to respiratory and cardiac emergencies.Students will learnto recognize and care for choking, breathing emergencies and cardiac emergencies for adults, children,and infants, as well as advanced aspects of CPR that includes two-rescuer CPR, airway management, use of a resuscitation mask, bag-valve-mask, and Automated External Defibrillator.

Information and Registration

1.Submit your registration form & payment byFebruary 10th. You can submit a paper copy or register online* at:

*Please note that an account must be created prior to making purchases online. Accounts must be approved by a staff member and may take up to 48 hours to process.

2.After registration, you will receive a link to the online coursework which must be completed before the skills session.

3.Do the online portion and bring your completion certificate to the skills session.

4.If you already have a CPR mask you do not have to purchase another one, but you must bring your own CPR mask to the skills session.

Registration forms due by February 10th.

CPR/AED for the Professional Rescuer

Registration Form

Name:______Date:______

Street Address:______

City/State/Zip:______

E-Mail: ______Phone: ______

First time certificationRecertification 

(Check the corresponding box) PSC:  Student  Faculty  Staff  None

Academic Major:______or Department: ______

CPR Course Fee$40.00 ______

CPR Pocket Mask$15.00 ______

Total Due: ______

Refund policy: 80% of the original cost will be refunded until 1 week prior to the start of the course. After that time, no refund will be issued, regardless of circumstances.

Please select one of the following:

 I have paid in cash.

 I have enclosed a check made payable to Paul Smith’s College.

 Please charge my credit card for a total of $______

 Visa MasterCard Discover

Card Number: ______Expiration Date:______

CCV (3 digits from the back of the card): ______

Address of card holder: ______

StreetCity State Zip

Name of Card Holder (as it appears on the card):______

Signature of Card Holder: ______

Waiver and Release of Liability

In consideration of being allowed to participate in any way in the PAUL SMITH’S COLLEGE program, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or other and assume full responsibility for my participation; and,

I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS PAUL SMITH’S COLLEGE, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

X______Date Signed: ______

(Participant’s Signature)

FOR ALL PARTICIPANTS OF MINORITY AGE(UNDER AGE 18 AT THE TIME OF THIS REGISTRATION)

This is to certify that I, as the parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above, of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

X______Date Signed______

(Parent/Guardian Signature)

Please return to: Recreation Coordinator

Office 106, Saunders Sports Complex

Paul Smith’s College Paul Smiths, NY 12970

P. 518-327-6097F. 518- 327-6545