Print this form and mail to UCHEP with Payment and Copy of Your BLS card.

UCHEP (05HL)

500 Foothill Dr.

Salt Lake City, UT 84148

 

REGISTRATION FORM:

ACLS 2007  VA Salt Lake City Health Care System

 

Course Dates: (Check One)    □ February 8 & 11, 2008  (0702U)  □ May 2 & 5, 2008   (0707U)   □ Sept. 5 & 8, 2008 (0713U)

 

Please print legibly:

Name: ________________________________________ 

Address: ______________________________________ 

City:  ___________________  State: _____ Zip: ______

E-mail Address:  _______________________________ 

Employer: _____________________________________

Home Phone:___________________________________

Work Phone:____________________________________

Text Box: Examination Preference (Check One):   □     Day II – Group I  (am  07:30 - 11:30) □     Day II – Group II (pm  12:00 - 4:00)   □     Proof of BLS Enclosed _____________

 

 

 

REGISTRATION:  Complete and return this form and payment to:  “UCHEP”, 500 Foothill Drive (O5HL), Salt Lake City, UT 84148 or Fax: (801) 588-0414

 

COST: 

     □  $10.00 VA Employees: non-refundable**  

     □   $10.00 Consortium members: non-refundable**      

     □   $100.00 Non-consortium members: non-refundable**

COURSE BOOKS:

Required:  American Heart Association 2006 ACLS Provider Manual (#80-1088)

Participants will not be admitted to course without having the course book in their possession at the start of the course. NO EXCEPTIONS! Participants should review course material and CD material prior to course.

 Optional:   American Heart Association 2005 Handbook of Emergency Cardiovascular (#80-1008)

VA Employees (excluding students and residents) will be provided the American Heart Association 2006 ACLS Provider Manual. To pick-up course book, please contact Julia Urbanek at extension 1947 or the Center for Learning Support Staff at extension 1948 / 1545.

Consortium members & Non-consortium members must provide their own books and can be ordered from one the following vendors:

CONSORTIUM HOSPITALS:   VA Salt Lake City Health Care System, University of Utah Medical Center, St. Mark's Hospital, Pioneer Valley Hospital, Jordan Valley Hospital, Salt Lake Regional Medical Center, Lakeview Hospital. To qualify as a consortium member, participants must be a paid employee of a consortium hospital.

  Please make all checks payable to UCHEP

Submission of this registration form indicates the participant has read and understands the course requirements

Amount Enclosed / Authorized Charge: $                                                      

Method of Payment:

□ Check

           □ VISA

□ Master Card

□ American Exp.

Account Number: ____________________________________________

 Expiration Date: ___ /____/______

Signature: ____________________________________________________________________________________________