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									                                              American Red Cross NorCal Coast Territory
                                            Authorized Provider/Training Provider Order Form
                                                                     Lifeguard Training & CPRO/AED

                                                     Send completed form to
  AP/TP Provider Information                                                                          Shipping Information
  Authorized Provider Name:                                                            I will pick up my order for no additional charge:
  Customer Contact Name:                                                              Santa Cruz Salinas Palo Alto San Jose Burlingame
  Phone Number:                                                                       San Francisco Oakland        Concord Santa Rosa
  Email Address:                                                                      Humboldt       Napa     Del Norte
  Date of Course:                                                                  (Please check with your selected pick-up office for available dates and times)

  Payment Information                                                               Please ship my order for an additional UPS charge to:
             Mastercard           VISA                   AMEX                       (Allow 7-10 days, see below shipping fees table, rentals not shipped)
             Purchase Order (attach copy of actual PO)
  Credit Card or PO Number:
  Expiration Date:                            Verification Code:

  UPS Shipping Fees Table
UPS Shipping Charges                      $0 - $20 = $5 | $21 - $50 = $8 | $50 - $100 = $10 | $101 - $150 = $15 | $151 - $200 = $20
Rentals cannot be
shipped                                   $201 - $250 = $25 | $251 - $300 = $30 | Over $300 please send in order for verification
  Product Name                              Stock       Cost Each   Qty.   Total     Product Name                           Stock    Cost Each       Qty.   Total
                                            Number                                                                          Number
  LIFEGUARDING: SHALLOW H20                                                          MISCELLANEOUS ITEMS
  Lifeguarding Participant Manual           655731      $34.99                       AED Trainer: Single Pack w/            N/A      $79.95
                                                                                     Carrying Case
  Rescue Mask, Soft Case; Adult &           N/A         $12.00                       AED Trainer: Six Pack w/ Carrying      N/A      $309.95
  Pediatric                                                                          Case
  Rescue Mask: Hard Case                    N/A         $10.00                       FIT Participant’s Manual               N/A      $5.25

  Bandage Practice Kit                      N/A         $4.00                        Adult Bag-Valve Mask                   N/A      $29.00

  DVD Set: Lifeguarding                     655732      $290.00                      Universal Certificate (10/per sheet)   N/A      $1.00 per
  Lifeguard Instructor Manual w/ CD-ROM     655730      $32.99                       RENTAL ITEMS (MUST BE
                                                                                     PICKED UP, PRICE BASED ON
                                                                                     24 HOUR RENTAL)
  CPR/AED FOR PROFESSIONAL                                                           Manikin, Adult w/ 2 free faces         RENTAL   $16.00
  CPRO/AED Student Handbook                 652168      $5.95                        Manikin, Child w/ 2 free faces         RENTAL   $16.00

  CPRO/AED Instructor Manual                652169      $25.95                       Manikin, Infant w/ 2 free faces        RENTAL   $16.00

  CPRO/AED Instructor Deluxe Kit            652176      $76.95                       Extra Faces—Adult                      RENTAL   $0.50
  (includes DVD)
  DVD: CPRO/AED                             652170      $51.95                       Extra Faces—Child                      RENTAL   $0.50

  GUARDSTART: LG TOMORROW                                                            Extra Faces—Infant                     RENTAL   $0.50

  Guardstart Workbook                       655714      $8.99                        DVD Set: Lifeguard Training            RENTAL   $6.50

  Guardstart Leader’s CD-ROM                655715      $22.00                       DVD: CPRO/AED                          RENTAL   $6.50

  DVD Set: Lifeguarding                     655732      $290.00                      AED Trainer: Laerdal                   RENTAL   $16.00


  Lifeguard Management Manual               654148      $26.99
  w/ CD-ROM
  Lifeguard Instructor Manual w/ CD-ROM     655730      $32.99

  DVD Set: Lifeguarding                     655732      $290.00

                                                        SUBTOTAL                                                                     SUBTOTAL
                                                        THIS SIDE                                                                    THIS SIDE
                                                                                                                                     TOTAL FROM
                                                                                                                                     BOTH SIDES

          Please allow 5 business days for your order to be processed. Orders cannot be placed until full payment or a copy of the actual PO is received. Email
    confirmations are sent with an electronic receipt once the order has been processed. Orders not cancelled 2 business days prior to pick-up date will be assessed
                                 a 10% re-stocking fee. Rush orders (less than 5 business day notice) will be subject to a 20% rush fee.

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