Course information

Course Type (Drop down Menu) *  CPR Level C Certification(BLS-C) CPR Level C Re-Certification (BLS-C) CPR Level C Certification (Health Care Professional) CPR Level C Re-Certification (Health Care Professional) Standard First Aid (CPR Level C and First Aid Certification) Standard First Aid RECERTIFICATION(CPR Level C Recertification and First Aid Recertification) Standard First Aid with HCP CPR (Health Care Professional CPR and First Aid Certification) Standard First Aid with HCP CPR Re-Certification (Health Care Professional CPR and First Aid Re-Certification) Emergency First Aid Certification Automated External Defibrillation Provider Oxygen Administration & Airway Maintenance Defibrillation/Oxygen Combo Course  

Date - Please type the dates of the course you are taking :*

Course Location:* London, ON - Robinson Memorial Church - 1061 Richmond St. Strathroy, ON Other (Place location in comment box above)

Par-Q Form
(Note: All information will remain confidential with BVD Emergency Training)

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes No

2. Do you feel pain in your chest when you do physical activity?
Yes No

3. In the past month, have you had chest pain when you were not doing physical activity?
Yes No

4. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Yes No

7. Do you know of any other reason why you should not do physical activity?
Yes No

I the undersigned, hereby acknowledge that certain risk of injury are inherent to participating in CPR/ First Aid/ Defibrillation/ Airway Maintenance courses and other athletic activities. These types of injuries may be minor or serious, and may result from one’s actions or the actions or inactions of others, or a combination of both.

I understand that the rules and regulations are designed for safety and protection of participants and hereby undertake to abide by these rules and regulations.

I understand that certain activities require a minimum level of fitness and health (physical, mental and emotional) and that each person has a different capacity for participation in these activities.

I agree that the location in which the training will occur or its employees, servants or agents shall not be liable for any injury to my person or loss or damage to my personal property arising from my participation in these activities, unless such injury, loss or damage is caused by the sole negligence of that location or its employees, servants or agents while acting in the scope of their duties.

I agree that BVD Emergency Training or its employees, servants or agents shall not be liable for any injury to my person or loss or damage to my personal property arising from my participation in these activities, unless such injury, loss or damage is caused by the sole negligence of BVD Emergency Training or its employees, servants or agents while acting in the scope of their duties.

I agree that Robinson Memorial United Church or its employees, servants or agents shall not be liable for any injury to my person or loss or damage to my personal property arising from my participation in these activities, unless such injury, loss or damage is caused by the sole negligence of Robinson Memorial Church or its employees, servants or agents while acting in the scope of their duties.

I declare having read an understood the above Informed Consent/Agreement in its entirety and hereby consent to participate acknowledging all of the foregoing.

Name of participant:*
Date Submitted:*