Providence Hospital
Emergency Department
1150 Varnum Street, NE
Washington, D.C. 20017
(202) 269-7664
Fax (202) 269-7997
Washington Metropolitan
Advanced Cardiac Life Support
Program
Leo C. Kelly, PA
Director
EXTENSION _____
Please Type or Print Clearly All Information
NAME: ____________________________________________________________TITLE:____________
Last
First
MI
MD/RN/DDS/PA/EMT/P/Etc...
HOME ADDRESS: ____________________________________________________ APT #__________
CITY: ___________________________________________________STATE:_______ ZIP: __________
Required for CME Credits & to get Replacement Card
WORK
SOC. SEC. #:________-_____-________ *** AFFILIATION: __________________________________
PHONE # :(Day) (_____) _________________________
(Eve) (_____) ____________________________
EMAIL Address ________________________________________________________________________
COURSE DATE
COURSE
CURRENT BCLS
REQUESTED: _________________LOCATION:________________________ EXPIRES__________
TUITION SCHEDULE
ACLS PROVIDER AND RENEWAL COURSE
Attending Physicians/ DDS/ DMD
$275.00 **
Residents/ Interns
$245.00 **
RN/ PA/ EMT/P/ Allied Health
$225.00 **
Renewal Course (1 Day with current new book)
All Applicants
$165.00 **
**It is expected that all participants will have a copy of the ACLS Text (Either ACLS Study Guide 4rd
Edition, Mosby or AHA ACLS
Textbook with CD) and the current ECC Handbook, the cost of which is included in the tuition. Except for Renewals stating they have the
current books. Additional or replacement copies are available at $75.00/set. Replacement Cards or ACLS Pins are $10.00 each.
All checks or Money Orders should be made payable to: “Washington Metro ACLS”
APPLICATIONS WILL NOT BE ACCEPTED ON THE DAY OF THE PROGRAM. In order to allow for the timely
distribution of course material, the application and tuition must be received at least three weeks prior to the date of the
scheduled program. Arrangements for pre-payment purchase orders may be made in advance with the Metro ACLS Staff.
Tuitions are used to defray the administrative and operational costs associated with the program and do not represent revenue
to Providence Hospital or the American Heart Association.
CANCELLATION/ REFUND POLICY
All cancellations must be submitted in writing. Tuition is Non- Refundable and Non-Transferable within two weeks of the
scheduled course. A $75.00 processing fee will be charged on all refunded applications. A $65.00 processing fee will be
assessed on all returned checks. If a student must reschedule at least two weeks prior to class date, there will be no charge for
the first reschedule, after that there will be a $50.00 reapplication fee. The reapplication fee will be applied to all “NO Show”
students that reschedule. The completed application, copy of BLS course completion and full tuition should be mailed to the
above address.
Signature:________________________________________________________Date___________________
I have read and understand the cancellation and refund policy.
*** REQUIRED FOR CME CREDITS FOR THE COURSE. NO CME will be given without SSN.