Red Cross Central Illinois Chapter

View Cart

Youth Class Request Form

Youth Class Request Form

Youth Class Request Form

Please complete and submit the form below to request one of more American Red Cross Youth Course(s) to be taught to your class or youth group.

*=required

*Your Name

*Phone Number

*Email Address

*Classroom Teacher or Youth Leader?

Grade

*School/Organization

*Address

Address 2

*City

*State

*Zip Code

*Phone Number

Fax Number

*Class 1

*Date Desired

Date:

Time:

*Class/Group Size

*TV/VCR Available?

*DVD Available?

Note: Please allow 3-4 weeks between today's date and your date selection. This form does not guarantee class can be taught on the date you have requested. We will call to finalize dates and times.

Class 2

*Date/Time

Date:

Time:

*Group Size

*TV Available?

*DVD Available?

Please list any special needs one or more children may have:

Additional Comments

© 2010 Red Cross of Central Illinois | Privacy Policy | Site Map
311 W. John H. Gwynn Jr. Ave. Peoria, IL 61605 • Phone: (309) 677-7272 • Fax: (309) 677-7283
404 Ginger Bend Dr., Champaign, IL 61822 • Phone (217) 351-5861 • Fax: (217) 351-5937
P.O. Box 1992, Danville, IL 61834 • Phone (217) 431-5600

Web Design and Web Development by the OIC Group