Advanced Trauma Life Support Provider Course Registration

Advanced Trauma Life Support Provider Course Registration

Please complete all information and return via email, fax or postal service using the information below.

Email:

Address: 720 Eskenazi Avenue; Hospital, 2nd Floor, Room 431; Indianapolis, IN 46202

Call the Wishard ATLS Office with any questions at (317) 880-5047

Course Dates: January 22-23, 2015

Name:

Mailing Address for book mailings:

City: State: Zip:

E-mail Address:

Phone Number:

Alternate Contact Number:

Fax Number:

Primary Specialty:

Hospital/Affiliation:

Active Duty Military:Yes No If Yes what is your rank

Course fee: $750

Recertification Course fee: $500

Course fees (check or money order only): Payable to “Wishard ATLS Course”

Once registration has been processed you will receive a confirmation letter and email regarding your participation in the course.

Please list any dietary restrictions as breakfast and lunch are provided: