Healthcare CPR Certification

HEALTHCARE CPR CERTIFICATION

Participant Information

Participant Name:

Female    Male    Other/Non-binary

Insurance Information

Provider:

Medical History & Limitations

Physical limitations that may affect participation: None indicated    Yes; if yes, describe below.

Course Information & Assessment

Basic Life Support (BLS)    CPR — Adult    CPR — Child    CPR — Infant    AED Use    First Aid

Written Exam Score:     Practical Skills Result: Pass    Fail

Instructor Attestation & Administrative Conditions

The instructor certifies that the participant demonstrated competency in the skills and knowledge requirements of the course listed above and met the minimum passing standards for both written and practical assessments. The certification is issued subject to the training organization's policies and may be suspended or revoked for evidence of fraud, noncompliance, or failure to meet professional standards.

Instructor attests to the above statement.

HIPAA / Privacy Acknowledgment

I acknowledge that personal health information collected for the purposes of training, assessment, and certification will be treated in accordance with applicable privacy laws and the training organization's privacy practices. Information necessary to validate certification may be disclosed to employers, credentialing entities, or regulatory bodies upon lawful request.

I acknowledge and consent to the above privacy terms.

Waiver, Release, and Certification Statement

By signing below, I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand the nature of cardiopulmonary resuscitation training and that physical exertion may be required. I knowingly assume all risks associated with participation, and to the extent permitted by law, I release the training organization, its instructors, and affiliates from liability for incidental injury arising from participation except for willful misconduct or gross negligence.

I understand that certification is valid through the expiration date above unless otherwise revoked or suspended, and that renewal requires successful completion of the applicable refresher or re-certification course.

I have read, understand, and accept the waiver, release, and certification statement.

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