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Resuscitation Course(s) Registration Form for Non-Employees
Name
Employer/Department
Credentials: Your Job Title
Email:
Daytime Phone #
Home Cell
Work
Evening Phone #
Home Cell
Work
Fax #
Mailing Address
Work
Home
City
Course Name
Registration
(Check all that apply)
Fee
Cell #:
State Zip
Date
Time
Confirmation must occur one week prior to class
ACLS 2-day Provider
$350.00
ACLS only Renewal
$250.00
ACLS Renewal w/BLS skills Lab
$325.00
ACLS Skills Lab*
$100.00
BLS Skills Lab*
$75.00
PALS Provider
$310.00
PALS Renewal
$260.00
PALS Skills Lab*
$75.00
NRP Skills Lab*
$75.00
ATLS
Check #
$800.00
Amount Charged
PALI use only
*Registration does not include the online didactic course. To have access to the online didactic course for ACLS, BLS, and PALS, go to
http://www.onlineaha.org/index.cfm?fuseaction=main.courseCatalog and complete the course. You will be asked to pay with a credit card
at this point. To have access to the NRP online didactic course go to http://www2.aap.org/nrp/ and complete the course. You will be
required to bring a certificate of completion to the Skills Lab.
AHA Disclaimer: The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has
developed instructional materials for this purpose. Use of these 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.
You may register by mail mail with a check made payable to PAMC, to
REGISTRATION, Providence Alaska Learning Institute,
PO Box 196604, Anchorage, AK 99519-6604.
Cancellation Policy:
Course fee for non-employees includes a $25 non-refundable charge, which reflects administrative costs in producing the course. The
remainder of the course fee, minus the cost of the textbooks, is refundable if cancellation notice is received by calling Providence Alaska
Learning Institute up to one working day before the program. If your course is cancelled, you will be referred to other courses, or your fee
will be refunded. No refunds will be given for partial attendance at any course or if you fail to call and cancel in advance.
Revised February 2014
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Revised February 2014