Public Safety First Aid (PSFA) Training Program Provider Application

Name of person completing this form *

First

Last

Phone *

Email *

Training Program/Individual Name *

Training Program Address *

Address Line 1

Address Line 2

City

State

Zip Code

Required Course Information

Principal Instructor(s) *

Teaching Assistant(s)

Required Documents

Resumes For Each Principal Instructor & Teaching Assistant *

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Course Outline *

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Sample Course Completion Certificate *

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Final Written & Skills Examination Documentation *

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Description of Program Facilities, Equipment, Examination Security & Student Record Keeping *

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Attestation

Outline Assistant Name

Date *

Electronic Signature *

First

Last

I attest that I have reviewed the S-SV EMS Agency PSFA Training Program Approval/Requirements Policy (1006) and will comply with all requirements described therein. I further attest that the training program meets or exceeds the public safety first aid and CPR course content requirements listed in California Code of Regulations, Title 22, Division 9, Chapter 2.3. I further attest that all information contained in this application and supporting documents is true and correct to the best of my knowledge.