LOYOLA UNIVERSITY HEALTH SYSTEM · Life Support Training Center

June 2016

Pediatric Advance Life Support (ACLS) with

Basic Life Support Renewal (BLS)

Please PRINT clearly

Legal Name Occupation or Program
Home Address Employer/Dept. or Coordinator
City/St/Zip Loyola Employee ID
Contact Number E-mail (employees must use assigned LUHS e-mail)

To register:

1.  Complete Registration Form. Will not be accepted with missing information.

2.  Copy of BOTH SIDES of Current AHA BLS provider card. If registering for PALS renewal, copy both sides of your PALS card.

3.  Provide Payment Information (LUHS staff upon successful completion of the course, and return of your student manuals, your payment will be voided or returned.)

4.  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:

PALS Recognition
7 a.m. – 7 p.m.
LUHS Employee Rate – $175.00 / Non – Employee Rate – $250.00
PALS Recognition Date: / PALS Recognition Deadline:
Thursday, June 16, 2016 / Thursday, June 2, 2016
BLS Renewal - BLS Renewal during PALS, is required for all Pediatric Staff that Does Not have ACLS through LUHS.
PALS Renewal
7 a.m. – 3 p.m.
LUHS Employee Rate – $140.00 / Non – Employee Rate – $175.00
PALS Renewal Date: / PALS Renewal Deadline:
Friday, June 3, 2016 / Friday, May 20, 2016
BLS Renewal - BLS Renewal during PALS, is required for all Pediatric Staff that Does Not have ACLS through LUHS.

DEADLINE: Classes are a first-come, first-serve basis. The deadline for registration is scheduled two weeks prior to the date of the course.

­  Check here if you would like course manuals mailed FedEx.

There will be an $15 additional charge.

IMPORTANT REMINDER: It is now required that you do the pre-course assessment submit it at the time of registration. Reviewing all the provided course materials is required for successful completion of the course.

Registration forms can be submitted:

§  Fax: 708-216-3127 (Fax number is a secure line)

§  Email:

§  In Person: Office Hours: Mon. – Fri. 7:30 a.m. – 4 p.m.

▪ Mail: Department of Nursing Education

Loyola University Medical Center

2160 South First Avenue,

Maguire Center, Bldg. 105

Room 2811

Attn: Amanda Michaud

Maywood, IL 60153

PLEASE NOTE: ABSOLUTELY NO REGISTRATIONS BY PHONE.

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: LUHS - Life Support Training Center

(American Heart Association Designated Center)

Phone: 708-216-3412

------DO NOT WRITE BELOW THIS LINE--FOR OFFICE USE ONLY------

Copy of BLS Card: No / Yes
Exp. Date : ______/ Copy of PALS Card for Renewals: No / Yes
Exp. Date ______
Payment: / CASH CHECK CREDIT CARD
Course Materials:
Books Letter / Picked-Up:______Mailed:______E-mail letter: ______
Date Received: