Course Request Fill out this form if you looking for a course not scheduled or to schedule training at your Organization/Business. Course Request First Name * Last Name * Organization/Business Name Email * Phone * Are you looking for individual training or for a Group? * Individual Organization such as a Church, Scout Troop, etc (Non Profit) Business (employees needing trained) Choose the option that best describes your needs. Do you require a written exam? * Yes No ** May be required by State Law or Employer, please verify if you need this. What type of Class would you like? * Instructor Led Blended (Online/Instructor Led) Online only Which category of training are you looking for? * Adult (Generally 12 years and older) Child (Generally 1 to 12 years old) Infant (Generally less than one year old) Select all that apply, this applies to the age of the person being treated for example do you want Adult CPR or Infant and Child First Aid, etc. Which Modules would you like included? * First Aid CPR AED First Aid for Severe Trauma (Stop the Bleed) Babysitter Training Asthma Inhaler Training** Epinephrine Auto Injector Training** Tourniquet Application Training** Instructor Training Choose all that apply ** Requires at least First Aid or CPR Options Would you like to purchase any materials or accessories? Participant Manuals - $11.99/ea Adult First Aid/CPR/AED Ready Reference - $3.95/ea Pediatric First Aid/CPR/AED Ready Reference - $3.95/ea Adult/Child and Infant CPR Mask - $12.95/ea Deluxe First Aid and CPR Training Student Kit with CPR Keychain Face Shield and Gloves - $6.95/ea My Medic Solo Basic First Aid Kit - $50.00 My Medic MYFAK Basic First Aid Kit - $120.00 My Medic Recon Basic First Aid Kit - $250.00 QuantityQuantity Please check all that apply, we will provide an estimate based on the number of students you provided for class materials. First Aid Kits and CPR Masks will have a qty of 1 unless notated in the Quantity box (check the box then add the number you would like to order). What Course Date are you looking for? * What location are you closest too? * Permian Basin (Midland/Odessa) Abilene, TX Albuquerque, NM Amarillo, TX Austin, TX Bryan, TX Corpus Christi, TX Dallas, TX El Paso, TX Harlingen, TX Lubbock, TX San Antonio, TX Texarkana, TX Tyler, TX Waco, TX Houston, TX Other What location are you closest too? This section applies to Organizations/Businesses only Address * Address Address 1 Address 1 Address 2 Address 2 City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Provide the address where you would like the training to take place How many students do you have? * Please enter the total number of students that will receive certifications. What date would you like to schedule the training? This does not guarantee the date chosen but is used as a guide. Please provide at least 2 weeks notice if possible, otherwise an expedite fee of $150 may be assessed. Would you like to require a written exam? * Yes No Not Sure ** May be required by State Law or Employer, please verify if you need this. How will the classes be paid for? * Organization/Business will pay Individuals will pay Is this training for EMS, Health Care or other First Responders? * Yes No There are varied courses that may apply if your organization is in the Health Care Industry Message Provide any additional details to help us facilitate your training. If you are human, leave this field blank. Submit