Salem Fire Foundation · Student-Taught CPR and AED Use

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Did you teach your family CPR?

Great job! Please fill out this form, and we will show our appreciation by sending you a small gift card.

Our hope is that students who watch our training video and take our quiz will go on to teach their parents and families CPR. This will help grow a community that is ready and able to assist in the case of a Sudden Cardiac Incident.

FOR STUDENT

Name

First Name

Last Name

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Did you watch our "Whose Life Will You Save Today?" video and successfully complete the quiz?

Yes

Did you teach at least two family members CPR after watching the video?

Yes

Name of First Family Member You Trained

First Name

Last Name

What is this family member's relationship to you? (E.g. Mother, Father, Aunt, Brother, etc.)

Please write the names of every person you taught CPR

For a family member who was taught CPR by the student

This student adequately taught me how to perform hands-only CPR

Adequate CPR includes: Scanning your surroundings, checking to see if the victim is breathing, having someone call 911, exposing the victim's chest, proper positioning of the hands-on the victim's sternum with one hand over the other, elbows locked in place, compressing down 2 inches at 120 beats per minute

Yes

FOR AN ADULT OVER THE AGE OF 18

Please write your name here as a virtual signature to verify that this student has fulfilled the above requirements

Please enter an address that we can mail the student's gift card to

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