**To help you prepare for this instructor course it is
strongly recommended that all candidates
attend a Healthcare Provider course
at Cooper University Hospital
within 30 days of the instructor course.**
Refund Policy:
Cooper Employees
A non-refundable cancellation fee of $125.00 will
be charged to Cooper employees who cancel less
than two weeks (14 days) prior to the date of the
course.
A “no-show” fee of $175.00 will be charged to
Cooper employees who do not show for the
course.
Refund Policy:
One Cooper Plaza, Dorrance #253
All candidates must successfully complete a
psychomotor skills evaluation on all adult and
pediatric BLS skills, plus a written exam on the
morning of the course to gain entry. All course
participants will be expected to perform
exemplary BLS psychomotor skills without any
coaching from the instructor. Any candidate who
does not successfully complete the BLS
performance skills evaluation and score at least a
90% on the written exam will not be able to
continue with the course and no refunds will be
given.
Camden, NJ 08103
Pre-Testing
Upon receipt of your completed registration form
and tuition, all candidates will receive the AHA
Core Instructor Course computer CD-Rom. This
course must be completed prior to coming to
class. The “Certificate of Completion” must be
printed and submitted to our office prior to the
course date.
BLS
Instructor
2013
Basic
Life
Support
Instructor Course
April 15, 2013
October 22, 2013
Non-Cooper Employees
Cancellation for this course must take place
4 weeks prior to the date of the course for a full
tuition refund. There will be no refunds or transfers
to another course for cancellations within four
weeks of the course date or for participants who
are unsuccessful on the written exam or skills
performance on the day of the course.
The Life Support Training Center reserves the right to deny course
registration requests if all required information is not provided.
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.
in conjunction with the
American Heart Association
New Jersey Affiliate
BASIC LIFE SUPPORT INSTRUCTOR
CANCELLATION / NO SHOW
LATENESS AGREEMENT
(please complete in full)
Name (please print)
ALL course participants must complete
and sign this agreement to complete registration. Employee ID #
Home Address
City
State
Professional Status
Employer Name
Work Phone
Department
Mobile Phone
Home Phone #
This nationally recognized instructor program is
intended for physicians, nurses, and allied health
professionals who are interested in teaching CPR.
Zip Code
____________________________________________
Participant Name (Please print) I do authorize Cooper University Hospital’s “Life Support
Training Center” to deduct from my paycheck the sum of
$125.00 for cancellation two weeks (14 days) prior to the
course or $175.00 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 $125.00 will be deducted
from my paycheck if I need to reschedule due to arriving to
the course late.
Email
Current AHA BLS / HCP Expiration Date: _______
Copy of card must be attached if course was not taken at
Cooper University Hospital
Circle Desired Course Date:
April 15, 2013
October 22, 2013
(Registration deadline is 30 days before course)
Enclosed with this form are:
______ Tuition Fee of $325.00
______ Letter of Recommendation from BLS Instructor
______ For Cooper Employees - $175.00 for required
manuals and AHA Core Instructor Course CD
There are no refunds or transfers to another course date given
to paying participants if course cancellation is less than two
weeks (14 days) prior to the course date, or if course
admission is denied due to lateness. Also there are no refunds
for participants who are unsuccessful on the written exam or
skills performance on the day of the course.
X__________________________________
Participant Signature
______________
Date
Director/Manager’s Approval
x______________________________________________
(Required for All Cooper employees)
Payment by credit card
Exp. date
Director /Manager’s Name: __________________________
(Please Print Name)
Director/Manager’s Signature: _______________________
Signature
Return registration & payment to:
Life Support Training Center
Camden, New Jersey 08103
________________
PCI/Book Sent



Current AHA Healthcare Provider Status
Exemplary BLS Performance skills
Letter of Recommendation from a
current AHA BLS Instructor
Completion of the AHA Core Instructor
Course
Course Dates:
April 15, 2013
October 22, 2013
Payment MUST be received with
completed registration forms.
Course Location & Time:
Cooper Hospital (Dorrance Building)
Classroom #256
Camden, New Jersey
9:00 a.m. - 5:00 p.m.
(856) 342-2009
FOR OFFICE USE ONLY
______________
Date Registered

For more information, please call:
One Cooper Plaza, Dorrance 253
_______________
Date Received
Prerequisites:
Cost Center/Dept #: _________________________________
Cooper University Hospital
FOR OFFICE USE ONLY
Each applicant must include a copy of their
current BLS Healthcare Provider card and a
letter of recommendation from a current
AHA BLS Instructor. Only complete
applications will be considered for the
course. Incomplete applications and those
without tuition fees, will be returned.
COOPER EMPLOYEES: If you wish to have your payroll
deducted $175.00 for the books, please sign here:
Credit Card #
Registration Information:
Shop:
LSTC
Total Charge:
Event:
BLS Inst Course
______________ Reason: _____________________
Or e-mail the office at:
LifeSupport@Cooperhealth.edu