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Ficha do Curso de Provedor DAN

Para o uso exclusivo de cursos de Formao de Provedores Complete uma ficha SEPARADA para cada Programa de Treinamento e envie a DAN dentro de 10 dias.

Endereo: DAN Training The Peter B. Bennett Center 6 W. Colony Place Durham NC 27705 USA

FAX: +1-919-490-6630

Email: oxygen@diversalertnetwork.org Instrutor Responsvel ____________________________________ Nmero do Instrutor DAN _____________________ Data do Curso ______/______/_____ Local do Curso _______________________________________ Ms Dia Ano Cidade__________________________________________ Estado ___________________ Pas ____________________ Assistente Certificado ________________________________Nmero Instrutor DAN ____________________________ Assistente Certificado ________________________________Nmero Instrutor DAN ____________________________ Eu atesto que os alunos relacionados abaixo completaram com sucesso as sesses de desenvolvimento de conhecimento e habilidades dos Programas de Treinamento assinalados, de acordo com os Padres de Treinamento DAN. Assinatura do Instrutor Trainer Responsvel: _____________________________ Data: _________________________ Programas de Treinamento (Selecione um)

Primeiros Socorros com Oxignio em Emergncias de Mergulho REMO2 Primeiros Socorros com Oxignio em Emergncias Aquticas Primeiros Socorros para Acidentes com Animais Marinhos Perigosos Desfibrilador Externo Automtico (DEA) para Mergulhadores

Lista dos Participantes do Curso

Membro DAN (Marque se positivo)

Nome Endereo (Rua, Cidade, Estado, CEP, Pais)

mailto:oxygen@diversalertnetwork.org

Instructor Name: Instructor Number: Course Date: Location: Course City: Certified Assistant 1: Assistant Number 1: Certified Assistant 2: Assistant Number 2: Signature Date: Training Program Selection: OffMember Check 1: OffStudent Name 1: Student Address 1: Member Check 2: OffStudent Name 2: Student Address 2: Member Check 3: OffStudent Name 3: Student Address 3: Member Check 4: OffStudent Name 4: Student Address 4: Member Check 5: OffStudent Name 5: Student Address 5: Member Check 6: OffStudent Name 6: Student Address 6: Member Check 7: OffStudent Name 7: Student Address 7: Member Check 8: OffStudent Name 8: Student Address 8: Member Check 9: OffStudent Name 9: Student Address 9: Member Check 10: OffStudent Name 10: Student Address 10: Member Check 11: OffStudent Name 11: Student Address 11: Member Check 12: OffStudent Name 12: Student Address 12: Member Check 13: OffStudent Name 13: Member Check 14: OffStudent Name 14: Reset Form: Student Address 14: Student Address 13: Course State: