F Lifesaving First Aid(with AED) Soins d`urgence

Sex/Sexe M
Aquatic Spinal Injury Management
Pressure-related Injury
Shallow Water Rescue
3
2
1
6
5
4
8
11
10
9
17
16
15
20
19
18
21
25
24
23
22
27
26
28
29
40
42
7
31
30
12
33
34
39
41
Result / Résultat
Diabetes, Seizure, and Poisoning
32
Test Score
Abdominal or Chest Injury
Bone or Joint Injury
Environmental Emergencies
Suspected Head Injury and Suspected Spinal Injury
Two Rescuer CPR
Secondary Assessment
Critical Incident Stress Management
Emergency Scene Management
Facial Injury
Care of an Unconscious Casualty
Wounds and Burns
35
38
37
36
Lifesaving Emergency First Aid / Premiers Secours
Lifesaving Standard First Aid / Premiers Soins
Aquatic Emergency Care / Soins d'urgence aquatique
YY
MM
DD
1
Circulatory Emergencies
Side 1: Please print each candidate's name and contact information legibly.
Respiratory Emergencies
q Original
Obstructed Airways- Unconscious Casualty
Lifesaving Emergency Frist Aid
Premiers Secours
Obstructed Airways- Conscious Casualty
q Recertification/Requalification
One rescuer CPR
q Original
AED Operation
Lifesaving Standard First Aid
Premiers Soins
First Aider Communication, Scene Assessment, and Primary Assessment
q Recertification/Requalification
Principles of First Aid, Workplace First Aid and Legal Requirements, and Self Protection
q Original
Prerequisites Checked
Aquatic Emergency Care
Soins d'urgence aquatique
Date of Birth -- Date de naissance
Lifesaving First Aid (with AED)
Soins d'urgence (avec DEA)
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
2
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
3
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
4
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
5
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
6
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone

Check box if there are more candidates on the reverse side of this page.
Cochez cette case s'il y a d'autres noms de candidats au verso de cette feuille.
Satisfactory Performance
Performance satisfaisante
Instructor information/Informations sur le moniteur
F
Total Pass for Exam
Total des réussite
Fail Échec
Total Fail for Exam
Total échec
Exam
information/Informations
sur l'examen
Exam date/Date
de
l'examen:
Instructor's name/Nom du moniteur
ID# / # d'identification
Y/A
M/M
E-mail/Courriel
(
(
)
Facility name/Nom de l'installation
Téléphone
Signature
q Exam fees attached/ Frais d'examen inclus
)
Téléphone
Awards information/Information sur le certificat
Payment information/Informations sur les frais
Awards issued by affiliate/Certificats émis
q Exam fees not attached/Frais d'examen non inclus
Awards not issued/Certificats non émis
Examiner information/Information sur l'examinateur
Send invoice or receipt to/Facturer à
(
Affiliation
)
Téléphone
Address/Adresse
City/Ville
D/J
Examiner's name/Nom de l'examinateur
ID#/# d'identification
E-mail/Courriel
Province
Postal code/Code postal
(
)
Téléphone
Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.
Veuillez retourner le formulaire dûment rempli au bureau local de la Société de sauvetage dès la fin du cours. Conservez-en une copie pour vos dossiers.
Signature
Sex/Sexe M
Aquatic Spinal Injury Management
Pressure-related Injury
Shallow Water Rescue
3
2
1
6
5
4
8
11
10
9
17
16
15
20
19
18
21
25
24
23
22
27
26
28
29
40
42
7
31
30
12
33
34
39
41
Result / Résultat
Diabetes, Seizure, and Poisoning
32
Test Score
Abdominal or Chest Injury
Bone or Joint Injury
Environmental Emergencies
Suspected Head Injury and Suspected Spinal Injury
Two Rescuer CPR
Secondary Assessment
Critical Incident Stress Management
Emergency Scene Management
Facial Injury
Care of an Unconscious Casualty
Wounds and Burns
35
38
37
36
Lifesaving Emergency First Aid / Premiers Secours
Lifesaving Standard First Aid / Premiers Soins
Aquatic Emergency Care / Soins d'urgence aquatique
YY
MM
DD
1
Circulatory Emergencies
Side 1: Please print each candidate's name and contact information legibly.
Respiratory Emergencies
q Original
Obstructed Airways- Unconscious Casualty
Lifesaving Emergency Frist Aid
Premiers Secours
Obstructed Airways- Conscious Casualty
q Recertification/Requalification
One rescuer CPR
q Original
AED Operation
Lifesaving Standard First Aid
Premiers Soins
First Aider Communication, Scene Assessment, and Primary Assessment
q Recertification/Requalification
Principles of First Aid, Workplace First Aid and Legal Requirements, and Self Protection
q Original
Prerequisites Checked
Aquatic Emergency Care
Soins d'urgence aquatique
Date of Birth -- Date de naissance
Lifesaving First Aid (with AED)
Soins d'urgence (avec DEA)
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
2
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
3
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
4
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
5
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone
Sex/Sexe M
6
F
Name/Nom
Address/Adresse
Postal code/Code postal
City/Ville
E-mail/Courriel
Téléphone

Check box if there are more candidates on the reverse side of this page.
Cochez cette case s'il y a d'autres noms de candidats au verso de cette feuille.
Satisfactory Performance
Performance satisfaisante
Instructor information/Informations sur le moniteur
F
Total Pass for Exam
Total des réussite
Fail Échec
Total Fail for Exam
Total échec
Exam
information/Informations
sur l'examen
Exam date/Date
de
l'examen:
Instructor's name/Nom du moniteur
ID# / # d'identification
Y/A
M/M
E-mail/Courriel
(
(
)
Facility name/Nom de l'installation
Téléphone
Signature
q Exam fees attached/ Frais d'examen inclus
)
Téléphone
Awards information/Information sur le certificat
Payment information/Informations sur les frais
Awards issued by affiliate/Certificats émis
q Exam fees not attached/Frais d'examen non inclus
Awards not issued/Certificats non émis
Examiner information/Information sur l'examinateur
Send invoice or receipt to/Facturer à
(
Affiliation
)
Téléphone
Address/Adresse
City/Ville
D/J
Examiner's name/Nom de l'examinateur
ID#/# d'identification
E-mail/Courriel
Province
Postal code/Code postal
(
)
Téléphone
Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.
Veuillez retourner le formulaire dûment rempli au bureau local de la Société de sauvetage dès la fin du cours. Conservez-en une copie pour vos dossiers.
Signature