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Push to Survive / Stop the Bleed Sign-up Form

  1. Sign up to attend a FREE class offered by the Draper Fire Department. Learn how to help save a life. This course is for educational purposes only. No certification will be provided. The class will be held at Station 22, 14324 S. Fire House Rd., Draper, UT 84020.
  2. Enter your first name.
  3. Enter last name.
  4. Enter your email address.
  5. Enter your phone number here.
  6. Is this reservation for an individual or a group?*
    Indicate whether you are registering for an individual, family or group.
  7. Enter the name of your group.
  8. Enter your group number.
  9. Leave This Blank:

  10. This field is not part of the form submission.