PEDIATRIC ADVANCED LIFE SUPPORT HOSPITAL EMPLOYEE REGISTRATION FORM
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1 PEDIATRIC ADVANCED LIFE SUPPORT HOSPITAL EMPLOYEE REGISTRATION FORM HOME ADDRESS TOWN/CITY/ZIP DEPARTMENT/FLOOR WORK PHONE HOME PHONE ( ) PA ( ) RN ( ) APRN ( ) Monday, March 16 and Tuesday, March 17 ( ) Thursday, July 9 and Friday, July 10 ( ) Thursday, October 8 and Friday, October 9 One Day Provider Recertification Courses ( ) Thursday, March 12 ( ) Thursday, April 30 ( ) Friday, June 5 ( ) Thursday, July 23 ( ) Thursday, October 29 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with this form or complete the section below to include appropriate signature to: Terry DeVito, R.N., M.Ed., CEN Fax: (860) MS#10201 Telephone: (860) To: Paul Freitas, Accounts Receivable, Finance Please transfer from Amount Account Number/Department Number/Cost Center To ACLS/PALS Account # SFCMP-SR0301-for Name To attend the at Saint Francis Hospital and Medical Center. Course/Date Manager or Department Head Signature Date Received by The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association
2 PEDIATRIC ADVANCED LIFE SUPPORT REGISTRATION FORM ( ) PA ( ) RN ( ) APRN ( ) MD ( ) Thursday, July 5 and Friday, July 6 ( ) Thursday, October 4 and Friday, October 5 One Day Provider Recertification Course ( ) Friday, June 8 ( ) Tuesday, December 18 Skill Validation Only for the On-Line Courses - $50.00 (2:00 p.m.- 4:00 p.m. Only) ( ) Friday, June 8 ( ) Friday, July 6 ( ) Friday, October 5 ( ) Tuesday, December 18 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with Terry DeVito, R.N., M.Ed., EMT-P, CEN Telephone: (860) St. Francis Care Community Training Center Fax: (860) The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association
3 PEDIATRIC ADVANCED LIFE SUPPORT PARAMEDIC REGISTRATION FORM PALS Instructor Course - $ Thursday, January 31 ( ) Monday, June 30 and Tuesday, July 1 ( ) Thursday, October 9 and Friday, October 10 One Day Provider Recertification Courses ( ) Thursday, April 24 ( ) Thursday, June 5 ( ) Friday, November 7 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with Terry DeVito, R.N., M.Ed., EMT-P, CEN Telephone: (860) Saint Francis Care Community Training Center Fax: (860) The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.
4 PEDIATRIC ADVANCED LIFE SUPPORT RESIDENT REGISTRATION FORM ( ) Thursday, July 5 and Friday, July 6 ( ) Thursday, October 4 and Friday, October 5 One Day Provider Recertification Courses ( ) Friday, June 8 ( ) Tuesday, December 18 Skill Validation Only for the On-Line Courses - $35.00 (2:00 p.m.- 4:00 p.m. Only) ( ) Friday, June 8 ( ) Friday, July 6 ( ) Friday, October ( ) Tuesday, December 18 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with Terry DeVito, R.N., M.Ed., EMT-P, CEN Telephone: (860) Saint Francis Care Community Training Center Fax: (860) The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.
5 PEDIATRIC ADVANCED LIFE SUPPORT PARAMEDIC REGISTRATION FORM ( ) Thursday, July 5 and Friday, July 6 ( ) Thursday, October 4 and Friday, October 5 One Day Provider Recertification Courses ( ) Friday, June 8 ( ) Tuesday, December 18 Skill Validation Only for the On-Line Courses - $50.00 (2:00 p.m.- 4:00 p.m. Only) ( ) Friday, June 8 ( ) Friday, July 6 ( ) Friday, October ( ) Tuesday, December 18 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with Terry DeVito, R.N., M.Ed., EMT-P, CEN Telephone: (860) Saint Francis Care Community Training Center Fax: (860) The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.
6 ADVANCED CARDIAC LIFE SUPPORT HOPSITAL EMPLOYEE REGISTRATION FORM LAST FIRST DEPARTMENT/FLOOR WORK PHONE HOME PHONE ( ) PA ( ) RN ( ) APRN ( ) Thursday, February 28 and Friday, February 29 ( ) Thursday, April 10 and Friday, April 11 ( ) Thursday, May 8 and Friday, May 9 ( ) Thursday, August 7 and Friday, August 8 ( ) Thursday, September 18 and Friday, September 19 One Day Recertification Courses ( ) Thursday, January 24 ( ) Tuesday, February 5 ( ) Tuesday, April 29 ( ) Tuesday, August 26 ( ) Friday, November 21 ( ) Friday, December 12 Please submit a check payable to Saint Francis Care for $ (Certification) or $ (Recertification) with this form or complete the section below to include appropriate signature to: Terry DeVito, R.N., M.Ed., CEN Fax: (860) Saint Francis Care Community Training Center Telephone: MS#10201 To: Paul Freitas, Accounts Receivable, Finance Please transfer from to ACLS/PALS Account# SFCMP-SR0301 Amount Acct#/Department Number/Cost Center For to attend the at Saint Francis Hospital and Medical Center. Name Course/Date Manager or Department Head Signature Date Received By The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.
7 ADVANCED CARDIAC LIFE SUPPORT PARAMEDIC REGISTRATION FORM LAST FIRST ACLS Instructor Course - $ ( ) Tuesday, January 15 ( ) Thursday, February 28 and Friday, February 29 ( ) Thursday, April 10 and Friday, April 11 ( ) Thursday, May 8 and Friday, May 9 ( ) Thursday, August 7 and Friday, August 8 ( ) Thursday, September 18 and Friday, September 19 One Day Recertification Courses ( ) Thursday, January 24 ( ) Tuesday, February 5 ( ) Tuesday, April 29 ( ) Tuesday, August 26 ( ) Friday, November 21 ( ) Friday, December 12 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with Terry DeVito, R.N., M. Ed., CEN Telephone: (860) Saint Francis Care Community Training Center Fax: (860) The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association
8 ADVANCED CARDIAC LIFE SUPPORT RESIDENT REGISTRATION FORM LAST FIRST ( ) Thursday, May 8 and Friday, May 9 ( ) Thursday, August 7 and Friday, August 8 ( ) Thursday, June 26 and Friday, June 27 ( ) Thursday, September 18 and Friday, September 19 One Day Recertification Courses ( ) Tuesday, April 29 ( ) Tuesday, August 26 ( ) Friday, November 21 ( ) Friday, December 12 Please submit a check payable to Saint Francis Care for $ (Initial Course) or $ (Recertification) with Terry DeVito, R.N., M.Ed., EMT-P, CEN Telephone (860) Saint Francis Care Community Training Center Fax: (860) The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.
9 ADVANCED CARDIAC LIFE SUPPORT REGISTRATION FORM ( ) APRN ( ) MD ( ) PA ( ) RN ( ) Thursday, February 28 and Friday, February 29 ( ) Thursday, April 10 and Friday, April 11 ( ) Thursday, May 8 and Friday, May 9 ( ) Thursday, August 7 and Friday, August 8 ( ) Thursday, September 18 and Friday, September 19 One Day Recertification Courses ( ) Thursday, January 24 ( ) Tuesday, February 5 ( ) Tuesday, April 29 ( ) Tuesday, August 26 ( ) Friday, November 21 ( ) Friday, December 12 Please submit a check payable to Saint Francis Care for $ (Certification) or $ (Recertification) with Terry DeVito, R.N., M.Ed., EMT-P, CEN Telephone (860) (Ronnie) or fax (860)
10 The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.
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