Full Name *

hereby authorizes Creative Dental Connections LLC to conduct an American Heart Association Heartsaver CPR/AED First-Aid Course.

Location *

Date(s) *

Time *

Number of students *

Course Fee Per Student *

On Site Convenience Fee: $50

Total Amount *

Final Payment Due (subtract $200 deposit) *

Terms & Conditions:

• Deposits are non-refundable. Credits may be used toward future classes. Final payment will be based on the total number of students attended.

• There will be a $50 rescheduling fee applied to the course if

Company Name *

fails to notify Creative Dental Connections LLC with at least 24 hours in advance notice. Fees will not be applied due to inclement weather conditions in which the course is cancelled

or rescheduled.

• Course completion cards will not be given until final payment has been processed.

By signing this agreement

Company Name *

has agreed to all the terms and conditions stated above.

The representative signing this agreement hereby attest to and agrees that she/he is a legal representative and has full authority to execute all that is stated in this agreement.

Signature of representative *