AHA Advanced Cardiac Life Support
Instructor Course (ACLS-I)
Jointly organized by
American Heart Association &
Hong Kong College of Emergency Medicine
Application Form
Course
AHA Advanced Cardiac Life Support Instructor Course (ACLS-I)
Date
25 March 2015
Venue
HKEC Training Centre, Pamela Youde Nethesole Eastern Hospital
Time
0830-1730
Limited quota (The HKCEM Resuscitation Subcommittee reserves
the final right on the acceptance of participants)
Course
Candidates must possess current AHA ACLS certification or
pre-requisites equivalent
Deadline
of
10 November 2014
Application
Quota
Personal Information:
Name in English
(same as ID Card)
Sex #
Name in Chinese
Male /
Female
Present Appointment:
Rank
Department
Hospital
Contact Information:
Address
Telephone
Mobile
Email Address
Professional Qualification [please tick one]:
HKCEM Fellow
Date conferred (year)
HKCEM Higher Trainee
Non-HKCEM Fellow/Trainee
Hong Kong College of Emergency Medicine
American Heart Association - Hong Kong
Address: Room 809, Hong Kong Academy of Medicine, 99 Wong Chuk Hang Road, Aberdeen, Hong Kong
Tel: (+852) 2871 8877
Fax: (+852) 2554 2913
Email: hkcem@hkam.org.hk
Website: http://www.hkcem.org
AHA Advanced Cardiac Life Support
Instructor Course (ACLS-I)
Jointly organized by
American Heart Association &
Hong Kong College of Emergency Medicine
Application Form
Payment –
Course Fee: HK$3,000;
Course material Delivery Method: Free (Self pick up at College) / $55 (Mail to Hospital by courier);
The cheque is payable to “Hong Kong College of Emergency Medicine”
Delivery Method
Self pick up at College /
Mail to Hospital by courier
Cheque Number
Amount
HK$
Bank
Delivery Address
Notes:
a) Please provide all information requested in the above table.
b) Please fax the photocopy of valid AHA-ACLS certificate before the instructor course date (25
Mar 2015)
c) Valid ACLS provider cert is one who has taken provider course within 2 years before the
instructor course date
d) Successful applicants will be notified by E-mail.
e) After completing the instructor course, the candidates should teach effectively in 2 ACLS
provider courses while being monitored (without honorarium) before attaining instructor
status.
f) Instructor should agree to teach at least 4 courses in a 2 year period to maintain instructor
status.
g) Course fees are not refundable once applicant is accepted into the course, unless the course is
cancelled.
h) Please send completed form with payment to HKCEM at
Room 809, Hong Kong College of Emergency Medicine,
99 Wong Chuk Hang Road, Aberdeen, Hong Kong
Signature:
Hong Kong College of Emergency Medicine
Date:
American Heart Association - Hong Kong
Address: Room 809, Hong Kong Academy of Medicine, 99 Wong Chuk Hang Road, Aberdeen, Hong Kong
Tel: (+852) 2871 8877
Fax: (+852) 2554 2913
Email: hkcem@hkam.org.hk
Website: http://www.hkcem.org