American Red Cross NorCal Coast Territory Authorized Provider/Training Provider Order Form Lifeguard Training & CPRO/AED Send completed form to PHSSNC@usa.redcross.org 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) Check 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 ATTENDANT/WATERFRONT/ WATERPARK 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 sheet 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 RESCUERS & HEALTHCARE PROVIDERS 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 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 SHIPPING FEES GRAND TOTAL 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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