1 Course Materials:
Pre-courseInformation and the mandatory pre-testwill
be sent to you upon receipt of your completed
registrationform and verification of course availability.
PALS
COURSE
REGISTRATION IS NOT CONFIRMED UNTIL YOU HAVE RECEIVED
THE PRE-COURSE INFORMATION. If VOU do not leCf?hrethe
pre-course information two weeks after submlttina vour
rt
realstration form. r lease contact the Llfe S u ~ ~ oTralnlnq
Center at 18561 342-2009. It is suggested that all
~artici~ants
read the 201 1 PALS Provider Manual prior to
coming to the course. The manual is available for
purchase from the LSTC for $40.00. (Themanual is
included for paying participants). Also available to help
you prepare for this course is a 2010 Emergency
Cardiovascular Care (ECC) handbook available through
the Life Support Training Center for an additional $25.00.
j
d Policy: Cooper Em~lovees
A non-refundable cancellation fee of $100.00 will
be charged to Cooper employees who cancel
2 weeks (1 4 days) prior to the date of the course.
A non-refundable "no-show" fee of $175.00 will be
charged to Cooper employees who do not show
for the course. (No Exceptions)
In addition, $75.00 will be deducted via payroll
deduction due to lateness and the need to
reschedule the course date or for not completing
the mandatory pre-test.
Refund Policy:
Non-Coo~erEm~lovees
Pediatric
Advanced
Life
Support
Cancellation for all PALS courses must take place
2 weeks (1 4 days) prior to the date of the course
for a full tuition refund minus the cost of the book.
THEREWILL BE NO REFUNDS OR TRANSFERRING TO ANOTHER
COURSE FOR CANCELLATIONS WITHIN TWO WEEKS (14 DAYS^
OF THE COURSE DATE.
Use of American Heart Association materials in an educational
course does not represent course sponsorship by the American
Heart Association. Any fees charged for such a course. except
for a portion of fees needed for AHA course materials. do not
represent income to the Association.
right to deny course registration requests if ali
required information Is not provided.
@ cooper
Lie Support Training Center
in conjunction with the
American Heart Associa tion
New Jersey Affiliate
CANCELLATION / NO SHOW
PRE-TEST / LATENESS
EXPIRED CARD AGREEMENT
PEDIATRIC ADVANCED LIFE SUPPORT
(please complete in full)
Name (please prlnt)
Cooper Employee ID#
ALL course participants must comdete
and sian this aareement to complete reaidration.
Home Address
City
State
Pmfesslonal Status
Social Securlty #
Employer Name
Department
Home Phone #
Work Phone #
Zip Code
Course Date Desired:
(Reaistration deadline is 30 davs before course)
Tuition: $300.00 Initial
$200.00 Renewal
(Course is free to Cooper employees
whose PALS completion card is current
the day of the course date)
I do authorize Cooper University Hospital's "LifeSupport
Training Center" to deduct from my paycheck the sum of
$100.00 for cancellation two weeks (14 days) prior to the
course or $1 75.00 for "No Show" under the terms and
conditions of the Payroll Deduction Agreement for the Life
Support Training Center with Cooper University Hospital. I am
also aware that a charge of $75.00 will be deducted from my
paycheck if I need to reschedule due to arriving to the course
late or for not completing the mandatory pre-test.
(No Exceptions).
I further authorize Cooper University Hospital to deduct $100.00
via payroll deduction if my PALS completion card expires
before I attend the course.
There are no refunds or transfers to another course date ghren
to paying participants U course canceliation is less than two
weeks (14 days) prior to the course date, or U course
admission is denied due to lateness or not compieting the
mandatory pretest.
X
Participant Signature
Method of Pavment
0
Participant Name (Please print)
Date
Check (Payable to: LSTC--Life Support Training Center)
Credit Card - Visa I Mastercard I American Express
Credit Card #
Signature
Return completed registrationform 8 tuition to:
Life Support Training Center
Cooper University Hospital
One Cooper Plaza, Dorrance 253
Camden, New Jersey 08 103
Director /Manager's Name:
(Please Pdnt Name)
DirectorlManager's Signature:
Cost CenterlDept #:
Prereauisites:
Participants must possess a current American Heart
Association Basic Life Support for Healthcare
Providers card. Copy of current BLS card must be
attached with this form, if course was not taken at
Cooper University Hospital.
FORPALS RENEWAL
COURSES. A COPY OF YOUR CURRENT
PALS PROVIDERCARD MUST BE ENCLOSED WITH THIS FORM IF
UNIVERSITY
HOSPITAL.
COURSE WAS NOT TAKEN AT COOPER
Please note: You
register and complete a
renewal course before your PALS provider card has
exoired.
2012 Initial Course Dates:
January 10 & 1 1
March 20 & 21
May9 & 10
June 5 & 6
July 26 & 27
September 18 &19
November 13 & 14
December 19 & 20
1 2012 Renewal Course Dates: I
1
Direcfor/Manager 's Approval
(Required for All Cooper employees)
Exp. date
Course Description:
The AHA'S PALS Course has been updated to reflect new sclence in the
2010 AH4 Guldefinesbr CPR 81 ECC
Thls dassroom, video-based, IWuctor-led course uses a series of
simulated pedlatric emergendes to reinforce the important concepts of
a systematic apprwch to pedlablc assessment, baslc Ilfe support, PALS
treatment algorithms, effective resuscitation and team dynamics. The
goal of the PALS Course is to improve the quality of care provlded to
seriously ill or injured children, resulting in improved outcomes.
Intended Audience:
The PALS Course is for healthcare providers who respond to
emergencies in infants and children. This includes personnel in
emergency response, emergency medicine, intensive care and critical
care unks such as physicians, nurses, paramedics and others who need
a PALS course compietlon card for job or other requirements.
January 27
February 9
April 1 1
May 29
June 21
I
July 20
September 25
October 9
November 9
December
3
I
.........................................................
-
i Course Location & Time:
3 Cooper Plaza, Suite 400
Camden, New Jersey 08103
9:30 a.m. - 3:30 p.m.
..........................................................
For further information, please call:
LSTC
Date Received
Date Registered
PCI/Book Sent
Shop:
BLS Exp.
PALS Exp.
Exp Fee Payment
Total Charge:
Event:
Reason:
PALS Course
Or e-mail the office at:
LifeSu~~od@Coo~erhealth.edu