Advanced Cardiac Life Support
Course Date:
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Circle one: Initial Course / Renewal Course
Time Started:
Time Ended:
Location:
Instructor:
Expiration Date:
Instructor/Student Ratio:
List of All Certified Students:
Name
& Email
1.
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Student/Manikin Ratio:
(Please print and write legibly)
Address
City
Zip
Phone #
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4.
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8.
Only advanced instructors may teach more than 6 students. Please contact for approval.
Texas Tech University Health Sciences Center TCID: TX04802 Coordinator: Olivia Hernandez
3601 4th St. STOP 8317
Lubbock, Texas 79430
T: 806 743 9272
F: 806 743 3045
simlife@ttuhsc.edu