LOYOLA UNIVERSITY HEALTH SYSTEM
January & March 2016
Advanced Cardiac Life Support Course (ACLS) with
Basic Life Support Renewal (BLS)
LUHS AHA Training Center
Please PRINT clearly
Legal Name
Occupation
Home Address
Employer/Dept.
City/St/Zip
Loyola Employee ID
Contact Number
E-mail (employees must use assigned LUHS e-mail)
To register:
1.
2.
3.
4.
Completed Registration Form. Will not be accepted with missing information.
Copy of BOTH SIDES of Current AHA BLS provider card. If registering for ACLS
renewal, copy both sides of your ACLS card.
Provide Payment Information (For LUHS staff, upon completion of the course, and
return of your student manuals, your payment will be voided or returned.)
Payment options: Cash, Personal check or money order payable to Loyola University
Medical Center, DISCOVER, VISA, MASTERCARD, or AMERICAN EXPRESS.
Credit Card #: _________________________________________________
Exp. Date : _______________________ V/Code: _____________
Name of Card Holder _________________________________________________
Zip Code: : ____________________
PLEASE SELECT WHICH COURSE YOU WOULD LIKE TO ATTEND:
ACLS Recognition
ACLS Renewal with BLS
LUHS – Employee Rate
LUHS – Employee Rate
Non – Employee Rate
Non – Employee Rate
ACLS Recognition with BLS
ACLS Renewal with BLS
Thursday, January 7, 2016
Thursday, January 21, 2016
Friday, March 4, 2016
Thursday, March 17, 2016
Friday, February 19, 2016
Thursday, March 3, 2016
PLEASE NOTE: ABSOLUTELY NO REGISTRATIONS BY PHONE.
Registration forms can be submitted:



Fax: 708-216-4759 (Fax number is a secure line)
Email: Amanda.Michaud@LUHS.org
In Person: Office Hours: Mon. – Fri. 7:30 a.m. – 4 p.m.
After Hours: 24 hr. Locked Drop Off Box
▪
Mail:
Confirmation:
An email will be sent your LUHS email (if you are an employee) confirming registration.
All registrants will receive information regarding when the course material will be
available prior to class. If you have not received the material at least one week prior
to class, please contact Amanda Michaud at 708-216-6077.
If this course is not a requirement for your position there is a possibility that you
may be rescheduled for a later date.
Cancellations: All cancellations must be received no later than FIVE business days
before the course date. Cancellations received less than FIVE business days before the
class and no shows will forfeit course fee.
For additional information contact:
Administrative Secretary:
Linda Nicol, RN, BSN, MBA
Patient and Life Support Education Manager
LUHS AHA Training Center Coordinator
Loyola University Health System
2160 S. First Avenue
Maywood, IL 60153
Phone: 708-216-4555
Amanda Michaud
Loyola University Health System
2160 S. First Avenue
Maywood, IL 60153
Phone: 708-216-6077
------------------DO NOT WRITE BELOW THIS LINE--FOR OFFICE USE ONLY------------------
Copy of BLS Card:
Payment:
Course Materials:
Books
IMPORTANT REMINDER: It is strongly recommended that you do the pre-course
assessment and study all provided materials or there is a possibility you will NOT pass
the exam.
LUHS - Life Support Training Center
Coordinator:
Exp. Date :
DEADLINE: The deadline for registration for each class is 2 weeks prior to the date of
the course. Classes are a first-come, first-serve basis, Maximum class size is 54
students, early registration is encouraged.
Department of Nursing Education
Loyola University Medical Center
2160 South First Avenue,
Mulcahy Center (Bldg. 106),
Room 0701
Attn: Amanda Michaud
Maywood, IL 60153
Letter
Date Received:
Copy of ACLS Card for Renewals: No / Yes
No / Yes
________________________
CASH
Exp. Date _______________________
CHECK
CREDIT CARD
Picked-Up:___________ Mailed:___________ E-mail letter: ______________