University CPR/AED Program Volunteer Rescuer Sign up Form

All fields are required.

First Name


Last Name

Phone (work or best daytime number)

e-mail

Employer
University University Student Research Institute KU Hospital Authority KUPI

Was your AED training on Zoll equipment?
   Yes
   No

Please provide a readable copy of the front and back of your card to Occupational Health Clinic.

If you are a University Student or a Research Institute Employee,  we also need your date of birth and your Social Security Number. 

You may provide the necessary information to Occupational Health Clinic in person, by fax at 8-2715, or leave a confidential voice mail message with this information at 588-1670,  or any other method you consider secure and timely. We do not recommend using Inter-Departmental mail.