Basic Life Support (BLS)

Centura, SASMC, VVMC Registration Form 2016/2017

Course Location: SASMC Classroom

4:00pm to 5:00pm

340 Peak One Drive, Frisco

Date Selection2016/ 2017:

Sept 21st Oct 19th Nov 16th Dec 28th

______

Jan 17th Feb 21st March 21st April 18th

May 16th June 20th July 18th Aug 15th

Sept 19th Oct 17th Nov 21st Dec 19th

Name:

Address:

City: State: Zip:

Email: Phone:

If you are not a Summit Medical Center employee, indicate which Centura facility you work for below and indicate your cost center for billing.

Please Note: We cannot process registrations without knowing your hospital/facility and cost center

***You must get your director to sign the registration form for all courses. Please remember that if it is not a required certification for your job description it will not be paid for unless you either pay it on your own or apply for the WSSG scholarship. Please ask your director about this process.

I am a SASMC employee (Supervisors Name: )

I am a Centura employee(Facility, Cost Center #, Supervisors Name: )

I am a VVMC employee(Supervisors Name: )

Supervisor Signature: ______Date: ______

In advance of class, you are required to complete the AHA web-based BLS course. The course normally takes about an hour to complete. SASMC and VVMC employeeswill receive an email from Katie Stillman with a pre-paid ‘coupon’ that will permit you to take the course without paying for it. Centura (non-SASMC employees) will need to submit for reimbursement for the online payment to AHA from their facility. If you don’t complete the course in advance of class, you will not receive your BLS card. The web site is:

For all students,The HEN will bill your hospital directly once you have completed the course. If you are a no-show or fail the class, your cost center will be notified that you were a no-show and billed for the class.Excusable absences: Emergency staffing need confirmed with manager, inclement weather, illness with a Doctors excuse.

Please Note: You can change classes or drop the classup until the time the class is “closed”. This will occur 14 days (10 business days) prior to the class start date. If you have unusual circumstances that arise and need to discuss it, just give us a call.

Once this registration is received in our offices, you will receive a confirmation letter via email. The confirmation email will include directions to the AHA website for preparation and review, and other information about the clouse.

Please return by Fax or Email to:

Katie Stillman

Health Education Network

Client Services Coordinator

Fax: (303) 312-1168Phone (303)380-0343

Please contact Katie with any questions or concerns