Registration

Step 1 of 2

Student Name(Required)

First Last

Date of Birth

Student Email Address(Required)

Student Telephone Number(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

Emergency Contact Name Relationship

Emergency Contact Phone Number

Course Title(Required)

Certification Provider(Required)

Course Date

Course Time

Training Location

Job Title

Employer

Professional License or Certification (if applicable)

License Number (Optional)

Do you require any accommodations under the Americans with Disabilities Act (ADA)?

If yes, please describe your requested accommodation.

Please list any medical conditions, allergies, or physical limitations that may affect your participation in hands-on skills practice.

Please acknowledge the following:

I understand that attendance for the entire course is required to receive certification.

I understand that skills testing is required for successful course completion.

I understand that certification is issued only after all course requirements have been successfully completed.

I understand that course fees may be non-refundable as outlined in Doyle's Life Support Academy's cancellation policy.

I consent to receive course reminders and certification notifications by email and text message.

Electronic Signature

By typing my name below, I certify that the information provided is accurate and I agree to the policies of Doyle's Life Support Academy.

Student Full Name

Date