*1.Information(Required.)

Title

Full Name

Department

Email

Phone Number

*2.Level requested(Required.)

Level III

Confirmation

*3.I confirm my understanding that this is a curriculum to be developed and not a course to be given as presented(Required.)

I confirm

I do not confirm

*4.I confirm that my organization meets the criteria that are specified as required to develop and give a course in, and deliver the course safely in my organization.(Required.)

I confirm

I do not confirm

*5.I confirm that in requesting and receiving this course, the CAFC has made no endorsement, verification or statement about my organization’s capacity to deliver this training safely(Required.)

I confirm

I do not confirm

*6.I confirm that my organization will assume all responsibility for the safe delivery of any course developed with this material and that CAFC will hold no responsibility(Required.)

I confirm

I do not confirm

*7.I confirm that my organization will provide a debrief on the use of the requested material within 1 year of receipt to the CAFC(Required.)

I confirm

I do not confirm