QPR Instructor Registration

By invitation only, the form below allows you to electronically complete the QPR Certified Gatekeeper Instructor Self Study Registration form. You should view the complete form prior to submitting the form below. Signing and submitting this form is the same as signing the registration form from QPR.

Please note that costs associated with QPR Gatekeeper Instructor training will be paid by Affirmation for those invited to become instructors.

"*" indicates required fields

First Name*

Last Name*

Address*

City*

State*

Zip*

Phone*

Email*

Day of Month*

Month*

Year*

Signature

Confirmation*

I have reviewed the complete the complete complete the QPR Certified Gatekeeper Instructor Self Study Registration form and agree with its contents, limitations, and terms. By submitting this form, I agree to have my information and signature affixed to a completed QPR Certified Gatekeeper Instructor Self Study Registration form and sent to the QPR Institute.

I have reviewed and agree.

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