Policy Details

5141.12 FORM Certification of Compliance with Procedure for Use of AED

5141.12

FORM - Appendix III

STUDENTS

Certification of Compliance with Procedure for Use of AED

I, _____________________________________ have read the Litchfield Public School System Procedure for Use of AED. I am aware of its contents and I am willing to comply with the procedures. I have had an opportunity to ask questions regarding the program and have had my questions answered. I at anytime, while functioning as a predetermined AED provider using the AEDs available in the Litchfield Public Schools, I have a question or concern, I will inform the school nurse who will provide me with clarification on the matter. I agree to follow the terms and conditions set forth under the Procedure for Use of an AED.

_______________________________________________ ________________________

Predetermined AED Provider Signature Date

_______________________________________________ ________________________

CPR/AED Instructor Signature Date

_______________________________________________ ________________________

School Nurse Signature Date


Litchfield Board of Education
Form Adopted: February 15, 2006

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