REVIVE! Lay Rescuer Training Registration

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* 1. Training date:

Date / Time

Date

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* 2. Trainer Name:

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* 3. First Name

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* 4. Last Name

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* 5. Home City/County:

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* 6. Home Zip Code

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* 7. Phone Number

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* 8. Email Address

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* 9. Age group

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 10. Gender

Male

Female

Other

decline to answer

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* 11. Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Multi-Race or Other race

decline to answer

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* 12. Do you consider yourself Hispanic/Latino?

Yes

decline to answer

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* 13. How did you hear about this training event?

Other (please specify)

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* 14. Why are you attending a REVIVE! training event?

Help others / save lives / be prepared

Interested in learning new skills or gaining certifications

Requirement (job/school/court)

Other (please specify)

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* 15. Are you willing to train others?

Yes

not sure yet