ADVANCED CARDIAC LIFE SUPPORT COURSE - RECERTIFICATION ONLY
Offered by Health Education Strategies, LLC
COURSE OBJECTIVE: The American Heart Association course is designed to teach providers the knowledge and skills necessary to
evaluate and manage an acute cardiac event or cardiac arrest. For providers who are expected to treat critically ill patients. An American
Heart Association ACLS Provider Card issued upon successful course completion.
PRE-REQUISITES: Current AHA ACLS & BLS-HCP Cards (include card copies, front & back, with registration)
Prior knowledge of EKG’s
REGISTRATION DEADLINE: Two (2) weeks prior to course date. Registrations received after the deadline will be subject to an additional
$10.00 late registration fee.
COURSE LOCATION: Health Education Strategies Training Site - 9095 Allen Road - Allen Park, MI 48101
CANCELLATION POLICY: Fees are NON-REFUNDABLE. Fee may be applied to a future rescheduled course if taken within six (6) months
of the cancelled course. Cancellations made within two weeks of the course will be charged an additional $75.00 rescheduling fee.
REGISTRATION FORM
(Please select course you will be attending and if you also require BLS-HCP training.)
Course Fee includes all course materials. Materials will be distributed upon receipt of payment. Refreshments are provided.
 I have AHA G2010 ACLS Manual (90-1014)
Deduct $20.00 from course fee.
ACLS RETRAINING-$180
(Include copy of current AHA ACLS card with registration and payment)
 I have AHA G2010 BLS-HCP Manual (90-1038)
Deduct $10.00 from course fee if taking with your ACLS.
BLS TRAINING-$60
 YES
 NO
(If NO, include copy of current AHA BLS-HCP card
with registration and payment)
 January 25, 2015
 February 22, 2015
 February 25, 2015
 March 29, 2015
 March 31, 2015
 April 26, 2015
 April 30, 2015
 May 28, 2015
 May 31, 2015
 June 28, 2015
 June 30, 2015
(8am – 4pm)
(8am – 4pm)
(3pm – 10pm)
(8am – 4pm)
(3pm – 10pm)
(8am – 4pm)
(3pm – 10pm)
(3pm – 10pm)
(8am – 4pm)
(8am – 4pm)
(3pm – 10pm)
 July 26, 2015
 August 30, 2015
 September 22, 2015
 September 27, 2015
 October 25, 2015
 October 29, 2015
 November 22, 2015
 November 24, 2015
 December 13, 2015
 December 16, 2015
(8am – 4pm)
(8am – 4pm)
(3pm – 10pm)
(8am – 4pm)
(8am – 4pm)
(3pm – 10pm)
(8am – 4pm)
(3pm – 10pm)
(8am – 4pm)
(3pm – 10pm)
Office Use Only
Materials Provided:
 ACLS Book  BLS Book
 Letter/Agenda/Map
 Receipt
PLEASE PRINT CLEARLY: H.E.S. is not responsible for lost mail.
 Mailed  Picked Up
Name: ______________________________________________________________________________
________________________
Credentials/Title: _____________________ E-mail Address: ___________________________________
Day Telephone: ____________________________ Night Telephone: ____________________________
Office Use Only
Home Mailing Address: _________________________________________________________________
Amt Pd: $___________________
City, State, Zip Code: ___________________________________________________________________
 Cash
 Credit Card
 Check  Money Order
#__________________________
Employer: _____________________________________ Department: __________________________
Date: ______________________
(U.S. Mailing Address Only)
PAYMENT MUST ACCOMPANY REGISTRATION
Please make check/money order payable to “Health Education Strategies, LLC” and mail to:
9900 Allen Road, Allen Park, MI 48101 (Canadian checks must be US Currency).
For further Information, Contact: Marilyn Enriquez at 313-388-7772/Fax: 313-388-2219
Email: healthedst@aol.com Web: www.healtheducationstrategies.com
Rec’d: ______________________
WE ACCEPT VISA/MASTERCARD/DISCOVER CREDIT CARD PAYMENTS
Card Number:
Expiration (Mo/Yr):
Total Amount
Security Code: _______________________________
(Located on Back of Card next to Signature Line. Usually 3 or 4 digits.)
Authorized:
Cardholder Name:
Cardholder Billing Address: _______________________________________________________________________
ADD
Late Registration
Fee - $10.00
Yes
I agree to pay above amount according to card issuer agreement.
Cardholder Signature:
The American Heart Association strongly promotes knowledge and proficiency in all American Heart Association courses 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.
Updated 04/29/2015