COURSE REGISTRATION FORM
HEALTHCARE TRAINING SOLUTIONS, LLC
TRAINING CENTER USE ONLY
P.O. BOX 777
LOVEJOY, GEORGIA 30250
RECEIVED ___/___/___
AMT PAID $ ____________
PHONE 404-587-1552
PAID BY: □ CASH□ CREDIT/DEBIT
FAX
678-561-8613
EMAIL: INFO@HEALTHCARETRAININGSOLUTIONS.ORG
# CARDS NEEDED __________________ DATE ____/____/____
2010 AMERICAN HEART ASSOCIATION COURSE SELECTIONSTUDENT INFORMATION
(SELECT ONLY 1 COURSE)
NAME: __________________________________________________
□ HEARTSAVER CPR
□HEARTSAVER FIRST AID
□AED
□BLOODBORNE PATHOGENS
□PALS
□PEARS
□ACLS
□BLS For Healthcare Providers
□PHLEBOTOMY
□ONLINE NURSE AIDE TRAINING
ADDRESS: ________________________________________________
_________________________________________________________
PHONE: __________________________________________________
EMAIL ADDRESS: ___________________________________________
WORKPLACE CPR & FIRST AID COURSES
□ HEARTSAVER CPR WITH AED □ CHILD □ INFANT □ ONLINE
□ HEARTSAVER FIRST AID ONLY □ ONLINE
□ HEARTSAVER FIRST AID WITH CPR & AED □ CHILD □ INFANT □ ONLINE
□ HEARTSAVER PEDIATRIC FIRST AID
□ CPR □ AED □ ONLINE
□ BLOODBORNE PATHOGENS
HEALTHCARE PROVIDER COURSES
□ BLS HEALTHCARE PROVIDERS
□ ACLS PROVIDER
□ PALS PROVIDER
□ PEARS PROVIDER
□ INITIAL
□ INITIAL
□ INITIAL
□ INITIAL
□ RENEWAL □ ONLINE SKILLS CHECK
□ RENEWAL □ ONLINE SKILLS CHECK
□ RENEWAL □ ONLINE SKILLS CHECK
□ RENEWAL □ ONLINE SKILLS CHECK
INSTRUCTOR PROGRAMS
□ HEARTSAVER INSTRUCTOR□ INITIAL □UPDATE
□ BLS INSTRUCTOR□ INITIAL □ UPDATE
□ ACLS INSTRUCTOR
□ INITIAL □ UPDATE
□ PALS INSTRUCTOR
□ INITIAL □ UPDATE
DATE OF COURSE: __________________________________________
OCCUPATION (OPTIONAL): ______________________________________
PLEASE SIGN BELOW IN ACKNOWLEDGEMENT OF THIS STATEMENT
I, __________________________________________, CERTIFY
THAT I HAVE PRE-PAID FOR THE SELCETED COURSE AND
UNDERSTAND THAT IT IS NON-REFUNDABLE. I UNDERSTAND
THAT IF I DO NOT SHOW UP FOR THE SCHEDULED CLASS, I WILL
FORFEIT MY PAYMENT AND AGREE TO A NEW REGISTRATION
AND PAYMENT TO RESHCEDULE THE PREVIOUSLY SCHEDULED
COURSE.
PRINT NAME : _____________________________________________
SIGNATURE: ______________________________ DATE ___________