2016 AHA Registration Form
Please fill out one registration form for each course you wish to attend. Each course you sign up for requires a $40.00
refundable deposit or payment in full if you are not an EPHC employee. Please send your deposit and registration form
by mail to Regina Martinez at EPHC 500 First Avenue Portola, CA 96122 or send via inner office.
Name:__________________________________________________________________
Address:________________________________________________________________
City:__________________________________________Zip:______________________
Phone : (home):___________________________(work):__________________________
Dept:______________________________
Campus: □ GMC □ IVMC □ LC □ PC
Date of course: _________________________
COURSE:
□ BLS Class on Portola Campus 9:00-1:00
□ BLS Class on Loyalton Campus 1:00-5:00* Call to confirm class availability.
□ ACLS Renewal Portola Campus 9:00-4:00
□ ACLS Provider Portola Campus 9:00-4:00 (2 days)
□ PALS Renewal Portola Campus 9:00-4:00
□ PALS Provider Portola Campus 9:00-4:00 (2 days)
COURSE MATERIAL:
□ AHA BLS (CPR) Manual
□ Purchase □ Borrow
□ AHA ACLS Manual
□ Purchase □ Borrow
□ AHA PALS Manual
□ Purchase □ Borrow
Please check the boxes that apply to you & note fee/deposit to include:
□ EPHC Employee _____________________$40.00 (refundable deposit)
□ EPHC Physician ______________________$40.00 (refundable deposit)
□ Non Employee ______________________call for pricing 530.832.6510
Make “CHECKS” payable to EPHC for:
* Deposit
* Books (buying or borrowing)
If paying by “CREDIT CARD” fax this registration form to 530.832.5395
Credit Card Number: ______-______ -______-______Exp Date ________
Signature: ____________________________________________________