NRP

St Anthony Summit Medical Center (SAMSC) & Centura Registration Form 2015

Course Location: ST AnthonySummitMedicalCenter

340 Peak One Drive, Frisco, Colorado80443

Mandatory Course Definition: Your hospital pays for the course and your time to take the course.

SASMC or Centura

I am a SASMC employeewanting to attend this course.

Manager or Director Signature for approval of mandatory class ______

Cost Center (we must have this for billing)

I am Not a mandatory SASMC student or I am associated with the hospital will be paying for the class myself

I work at the following facility: For non-mandatory SASMC students: You can apply for the WSSG

Scholarship to pay for this class! Ask your director about this process.

I am a Centura Employee and I work at the following Centura facility:

Manager or Director Signature for approval of mandatory class ______

Cost Center (we must have this for billing)

I amnot a mandatory Centura student and will be pay for the class myself- thus not needing Manager approval.

VVMC

I am a Vail Valley Medical Center employee wanting to attend this course

Manager or Director Signature for approval of mandatory class ______

I am not a mandatory VVMC student or I am associated with the hospital will be paying for the class myself

I work at the following facility:

VVH

I am aValley View Hospital employee wanting to attend this course.

Manager-Nancy Smith signature for approval of mandatory class ______

I amnot a mandatory VVH student and will be pay for the class myself- thus not needing Manager approval.

Name:

Email: Phone:

______

2015 Course Dates:

January 14th May 6th August 13th

Class time: Class takes two hours, but plan on being available from 9-4 on the day of class. Ten days prior to class, a 2 hour time slot will be assigned to you. Your time slot and any additional information will be sent to your email address.

In advance of taking the NRP course, you are required to complete the web based examination. Access to the course is only available through Healthstream. By registering for the Neonatal Provider Resuscitation course, you acknowledge that you will complete the online NRP examination prior to class and review the NRP manual in advance of class.

SASMC or Centura

If you are a SASMC employee, you will receive an email from Janice Schmidt that will provide you with direct access to the web based examination. You may also pick up and borrow an NRP manual from Janice. Alternatively, you may purchase the NRP manual directly: or acquire it on your own. Janice’s email is

If you are a Centura(but not a SAMSC)employee: Please contact your training department to get access to the Healthstream web site for taking the examination and/or acquire an NRP manual. Alternatively, you maypurchase the NRP manual directly: or acquire it on your own.

For a student guide to taking the course, go to:

Credit card information MUST be given to process your registration: This card will NOT be charged unless you are aNO SHOW for FAIL the class. If you are a NO SHOW or FAIL the class, your credit card will be charged $125. The HEN will bill ALL participant hospitals directly once you have completed and passed the course.

Excusable absences: Emergency staffing need confirmed with manager, inclement weather, illness with a Doctors excuse.

Please Note: You can change classes or drop the class up 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.

Credit Card #: Type: MC VISA DISC

Exp date (mm/yyyy):

Name as it appears on the card:

Electronic Signature (type name here):

Once this registration is received in our offices, you will receive a confirmation email with more information about the class.

Please return by Fax or Email to:

Katie Stillman

Client Services Coordinator

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

Please contact Katie with any questions or concerns