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									                                                                     American Red Cross
                                          Authorized Provider Request for Blended Learning Offering
American Red Cross Authorized Providers should use this form when requesting a "Blended Learning course". This form will provide the American Red Cross
Team the information necessary to create the offering and provide customers with a link to access the online training.
                                                                One Class Request Per Form.
                               All fields must be completed. Email completed form to:

    Requestor's Information
First Name:                                                                                   Last Name:
Title:                                                                                        Phone Number

   Authorized Provider Information
Business/Organization Name:                                                                   Organization ID (if known):
Billing Address:                                                                              Billing City:
Billing State:                                                                                Billing Zip:
Authorized Provider Contact Name:                                                             Contact Phone Number
Contact e-mail address                                                                        Contact Fax Number

   Offering Request Information
Course offering being requested:
Start date (earliest date for students to access training):
Date of Skill Session
Start Time of Skill Session
End Time of Skill Session
Number of students who wil be attending offering:

  Where will training take place?
Name of Site                                                                                  Address:
City:                                                                                         State:
Zip:                                                                                          County:

Directions to request Blended Learning Class
When completed, e-mail form to with "Blended Learning                                                         TSC Use Only
Request" in the subject line. Please allow 2 business days for processing of all requests.                                  Agent Name
Once the class is set up, the contact on the request will receive an Offering ID and a deep                                 Date Processed at TSC
link that students can use to enroll in this class. You may request one offering per form.
After your organization has completed the classroom portion of this offering, please email                                  Offering ID
your course record to with "Completed Blended Learning                                         Date ID sent to Customer:
Class Info" in the subject line. NOTE: You will need to reference the Offering ID number                                    Agent Comments:
on course record and any correspondence referencing this class.

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