LOYOLA UNIVERSITYHEALTH 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. Completed Registration Form. Will not be accepted with missing information.
  2. Copy of BOTH SIDES of Current AHA BLS provider card. If registering for ACLS renewal, copy both sides of your ACLS card.
  3. Provide Payment Information (For LUHS staff, upon 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:

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 21, 2016 / Thursday, January 7, 2016
Friday, March 4, 2016 / Friday, February 19, 2016
Thursday, March 17, 2016 / Thursday, March 3, 2016

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.

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.

PLEASE NOTE: ABSOLUTELY NO REGISTRATIONS BY PHONE.

Registration forms can be submitted:

  • Fax: 708-216-4759 (Fax number is a secure line)
  • Email:
  • In Person:Office Hours: Mon. – Fri. 7:30 a.m. – 4 p.m.

After Hours: 24 hr. Locked Drop Off Box

▪ Mail: Department of Nursing Education

Loyola University Medical Center

2160 South First Avenue,

Mulcahy Center (Bldg. 106),

Room 0701

Attn: Amanda Michaud

Maywood, IL 60153

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

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

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