Stop The Bleed Course Request

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Please complete the form below to submit your request to have a University of Utah Health representative bring the Stop The Bleed course to your location. The course is ~60 minutes in length (40 minutes of instruction & 20 minutes of hands-on training) Keep in mind: the course is most appropriate for ages 12+ but can be adapted for children as young as 8.

COMPLETION OF THE FORM DOES NOT GUARANTEE COURSE IS SCHEDULED-you will be contacted by phone or email within 3-5 business days to discuss your request and confirm a date. The more notice you can give us, the more likely it is that we can find instructors.

If you are interested in attending a Stop The Bleed course in downtown SLC, we hold them the 2nd Tuesday of every month. Go here to register; otherwise, proceed with this form. Thank you for your interest in spreading this vital information & education!

Email *

PRIMARY CONTACT Name, Phone Number (& Email, if different from above) *

SECONDARY CONTACT (if any) Name, Phone & Email

Address/location where course would be held (include name of building/business) *

Which option best describes your primary audience? *

Childrens' group/ages 8-11

In-School/ages 12+ (classroom training for students)

Youth group/ages 12-18 (church group, scouting, after-school event, etc)

University of Utah students, staff or faculty (campus event or activity)

Community group/adults 18+ (church, rotary group, meetup, social event, etc)

Workplace/ages 18+ (place of business; employees are primary attendees)

Other:

How many would be in attendance? We like to have at least 4 attendees. *

4-10

11-20

21-30

30+

Other comments:

Preferred dates/times (provide a few options, if possible)

How did you find us/hear about us? Select all that apply:

Stop The Bleed website

Attended a STB course

Referral (family/friend told you about us)

Social media posting

University of Utah Health Resource

Other:

Are there any special needs, accommodations or experiences we need to be aware of?

A copy of your responses will be emailed to the address you provided.

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