HeartCode ACLS Provider Course
Registration Request Form
Return Completed Form to:
UMC Training Center - Department of Emergency Medicine
(Fax) 601-815-5950
A.
Date of expiration on current ACLS Provider card: __________________________________
B.
Please attach a copy (FRONT AND BACK) of your current ACLS Provider card to this form.
C.
Are you a UMC Employee?
 Yes, UMC ID #_____________________________
Department/Unit_________________________________________________
Manager’s name ________________________________________________

Student ID # ___________________
 No, I do not work @ UMC. Place of Employment_________________________________
D.
Payment Enclosed (we cannot accept cash payment, personal check or credit card):
$150, UMC employees / UMC student
$200, Non-UMC employees
_____Interdepartmental Invoice for UMC employee
_____Cashier’s Check or Money Order payable to "UMC TC"
(non-UMC employees, self-paying UMC employees/student)
E.
Name________________________________________________________________
(Last)
(First)
(Middle)
Last 4 Digits Social Security #_________________
Address______________________________________________________________
City_______________________
State_________
Zip______________
Work Phone _______________________Home or Cell Phone___________________
Fax No. (___)__________________
F.
Please check:  Dentist
 EMT-P
 Physician
 Nurse Practitioner

G.
Email________________________________
 RN
 EMT-I
 Pharmacist
 Respiratory Therapist
Other Healthcare Provider (please specify)______________________________
Please specify preferred location to complete the course:
 Training Center / JMM
 Main Hospital
----------------------------------------------------------------------------------------------------------------------------For Administrative Use Only:
1.
Date Request Form Received________________________ Request Form Complete_________________
Request Form Incomplete; Date Returned to Sender____________________
2.
Login/Password Assigned_____________________________ Date Sent to User______________________
3.
____ HeartCode 1 (H273 UMC Hospital Education only) ____ HeartCode 2 (H273)
4.
 Course Complete
____ HeartCode 3 (TC Jackson Medical Mall)
 Course Incomplete
5. Date Course Completion Card Sent_____________________________________
UMC Training Center
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