CLASS REQUEST INFORMATION SHEET

CLASS REQUEST FORM

EdCor can conduct any of our class types at your office, facility or you can have a private class at an EdCor office. Advanced lead time for the class request and date options greatly help in confirming instructors and the the class.

Complete the information you can for your class request. Once it is submitted EdCor will contact you for scheduleing and confirmation. Any Additional information or questions can be entered at the bottom in the Additional InformationQuestions section.
Contact Information
Name of Company or Facility/Location*
Name of Person Completing Form
If different than the Class Point Person
Class Coordinator*
Title/Department
Email Address*
example@example.com
Phone Number*
Preferred Contact Method

PhoneEmail
Send Certification IDs to:
If a listing is needed separate from the students providing their certifications.
COID # / COST CENTER / Dept Code
If needed for Invoicing
Billing Contact*
Billing Contact Name
Billing Contact Email Address
example@example.com
Billing Contact Phone Number
Class Information

Preferred class dates, times, class type and number of students.
Preferred Class Date*

MonthDayYear
For two day classes this would be the first date
Class Time*
Enter preferred start time if you prefer a specific time or enter Morning, Afternoon, Evening or Flexible.
Alternate Class Date #1

MonthDayYear
Date
Alternate Class Date #2

MonthDayYear
Date
Class Type*

BLS (Basic Life Support)TNCC Provider (2-day)ACLS (Advanced Cardiac Life Support)TNCC Renewal (1-day)PALS (Pediatric Advanced Life Support)ENPC (2-day)ASLS (Advanced Stroke Life Support)NRPPEARS (Pediatric Emergency Assessment, Recognition & Stabilization)QMAP (2-day)Heartsaver (non-medical providers - CPR and/or First Aid - with certification)Stop the BleedFamily & Friends CPR\AED (no certification)Group Mega CodesECG/EKGOther
Heartsaver Class Modules*

Adult CPR/AEDChild CPR/AEDInfant CPR/AEDFirst-AidPediatric First-AidUnknown, Other, Need to discuss what is appropriate for our Orginization
BLS Class Formats*

BLS Provider - Available to new or expired students. Class is approximately 3.5 hours long.BLS Renewal - All participants must provide their current AHA BLS certification. Class is approximately 2 hours long.HeartCode (skills class) - Hybrid learning course. Students complete the AHA BLS HeartCode online prior to classroom session. The classroom session is 1.5 hours and focuses on the hands-on portion.Unknown/Need to Discuss
HeartSaver Class Formats*

All Classroom - Requires no pre-work, all material and hands on sessions are covered during the classroom session.HS Skills - Hybrid learning course. Students complete the AHA HeartSaver Heartcode online prior to classroom session. The classroom session is ~2 hours (depending on selected modules), and focuses on the the hands-on portion.Unknown/Need to Discuss
ACLS/PALS Class Formats*

Provider - Available to new or expired students. 2-day classroom class with required online pre-work.Provider 2-days in 1 - (Only available for ACLS) Available to new or expired students. 1 extended classroom day with required online pre-work. (Not recommended for students new to the field)Renewal - All participants must provide their current AHA ACLS or PALS certification. 1-day classroom class with required online pre-work.HeartCode (skills class) - Hybrid learning course. Students complete the AHA HeartCode online prior to the classroom session. The classroom session is 1.5 - 2 hours long and focuses on the hands-on portion.Unknown/Need to Discuss
Will Students be renewing their BLS during the ACLS/PALS class?*

YesNoI would like more information
Number of students*
The number of students expected for the class or a range of the number of students
Private Class Student Requirements
- CPR (BLS and HeartSaver) Classes
  - Minumum number of students is 5 students per session.
  - Classes of 10 - 13 students, the class will be scheduled as multiple sessions with a single instructor. Sessions can be back-to-back or different days to accomodate differences in schedules.
  - For classes of 14 - 18 students, the class can be scheduled as multiple sessions or a single session with two instructors. If scheduled as a single sesion with two instructors the minimum invoice will be for 14 students.
- ACLS, PALS, PEARS and Megacode Classes
  - Minumum number of students is 4 students per session.
  - For classes with more than 9 or more students, the class will be scheduled as multiple sessions.
- TNCC, ENPC and NRP Classes
  - Minumum number of students is 4 students per session.
  - For classes with more than 7 or more students, the class will be scheduled as multiple sessions.
- QMAP, ECG/EKG Classes
  - Minumum number of students is 8 students per session.
  - For classes with more than 15 or more students, the class will be scheduled as multiple sessions.
  - Note: Depending on the class size the orginizaiton may need to provide a test proctor on day 2 to allow for written testing and practicum testing to overlap.
Classes smaller than the minimum number of students can be scheduled, but will be invoiced based upon the student minimum.

For large group classes please enter the estimated number of students and EdCor will discuss scheduling options when we contact you.
Will you need new course books? Please note: AHA books are required and must be the current 2020 guidelines edition BLS, ACLS, and PALS. Other book current editions are - TNCC 9th edition, ENPC 6th edition and NRP 8th edition

YesNo - class participants have access to the current bookPlease send more info
Names and Email Addresses of Class Participants (if known)
This will allow us to register them in the class and send preparation/study material and a reminder email to the participants
Class Location
Street Address*
Building/Suite #
City*
State
Zip*
AV Equipment
Does the room have any existing AV Equipment such as wall mounted TV or projector?
Type of room*

ClassroomConference Room/Break RoomWaiting Room/LobbyOther
Additional Information and Questions
Any additional information that may help in the scheduling process, what type of class you are looking for or questions that you have.
How did you hear about us?

Previous ClassWeb SearchConferenceReferred by EmployerFacebookOther
Does your site have an AED?

YesNoNo, but we are interested in purchasing an AED
Please note that submitting this form does not guarantee the class date. EdCor will contact you for scheduling and will send a confirmation when the class is scheduled.
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