I. PERSONAL INFORMATION (If filling out on behalf of a group/company, the person in charge must fill out the details in this section)
- Title: (select one)
- [X] Mr.
- [] Mrs.
- [] Ms.
- [] Other
Alex Sandaval
Gender: (select one)- [x] Male
- [] Female
21/09/2001
Residential Address:
Dream Tower, Ginger St. Floor 14, room 7
Phone Number:
01004845
Email:
[email protected] (( Rykeheart ))
(( Discord: ))
Johhrykeheart
II. GROUP/COMPANY INFORMATION (if applicable)
- Group/Company Name:
ANSWER
Number of Participants: (Make sure to verify the number of participants internally prior to completing this form, as the fee will be determined based on the total number of participants, regardless of any no-shows)
ANSWER
Names of Participants: (Add more lines if required, delete extra ones if unneeded)- LIST HERE
- LIST HERE
- LIST HERE
- LIST HERE
- LIST HERE
- [] Yes
- [] No
- If yes, please specify: ANSWER
ANSWER
III. COURSE DETAILS
- Select Course Option: (Hemorrhage Management & Control until EMS Arrival and CPR & AED are mandatory, the following two are optional modules which you may additionally choose from)
- [X] Burns
- [X] Recovery Position
- [] None of the above optional modules
I look forward to joining the Arcani Group volunteer search and rescue team and in the future I intend to apply for a police force. Having even basic first aid information in either of these endeavors would make me much more proficient and useful.
Availability Dates & Times: (Provide us with a list of your top 3 preferred dates and times for your first aid session, add more lines if you want to include more. Please note that we cannot guarantee availability on those specific dates and times)- 09/06/2025 - 00:00 - 5:00
- 10/06/2025 - 13:00 - 5:00 Next day
- 12/06/2025 - 13:00 - 5:00 Next day
- 13/06/2025 - 13:00 - 5:00 Next day
- Enrollment in the First Aid Courses offered by Pillbox Hill Medical Center is confirmed upon receipt of the completed enrollment form and full payment. Enrollment is subject to availability, and spaces are allocated on a first-come, first-served basis.
- The standard course fee is $10,000 per individual, covering mandatory modules (Hemorrhage Management & Control until EMS Arrival and CPR & AED). An additional fee of $5,000 per individual is applicable for each optional module (Burns and Recovery Position). Group discounts may be available; please contact Pillbox Hill Medical Center for further details.
- Payment for the course must be made in full at the time of enrollment. Payment can be made via bank transfer, or cash. Payment instructions will be provided upon submission and subsequent reception of the enrollment form.
- Cancellations made more than seven days prior to the scheduled course date are eligible for a full refund. Cancellations made within seven days of the course date are non-refundable. However, participants may transfer their enrollment to another individual or reschedule for a future course date, subject to availability.
- Pillbox Hill Medical Center reserves the right to modify the course schedule, including dates, times, and locations, due to unforeseen circumstances or low enrollment. Participants will be notified in advance of any changes to the course schedule.
- Participants are responsible for attending the session of the course and actively participating in the learning activities. Failure to attend or complete the course does not entitle the participant or the company for which the participant works for to a refund.
- Upon successful completion of the course, participants will receive a certification of completion from Pillbox Hill Medical Center (( Our team will provide you with a customized certificate item that can be used for roleplaying purposes as a first aid certificate. However, please note that this certificate is not officially recognized. It is merely for aesthetic purposes. The only official aspect is that we will register your names in ours and the LSFD's database. ))
- Participants acknowledge and understand that participation in the First Aid Courses involves certain risks and hereby release Pillbox Hill Medical Center, its employees, instructors, and affiliates from any liability for injury, loss, or damage incurred during the course.
- Any personal information provided on the enrollment form will be kept confidential and used solely for the purpose of administering the First Aid Courses. Pillbox Hill Medical Center adheres to all applicable privacy laws and regulations.
- By signing below, I confirm that I have read, understood, and agree to abide by the terms and conditions outlined above.
- Signature:
Alex Sandaval
Date:
08/06/2025
