MOSES CONE HEALTH SYSTEM
CONE HEALTH
ADVANCED CARDIAC LIFE SUPPORT
COURSE REGISTRATION FORM
In order to process, please complete ALL information.
TARGET AUDIENCE: Healthcare providers not employed by Cone Health.
Please book early - classes fill quickly.
Complete form and mail to:
Cone Health
Staff Education
1200 N. Elm St.
Greensboro, NC 27401
Include:
• A copy of your current BLS Healthcare Provider card (current BLS is a prerequisite for ACLS).
• Complete pre-course self-assessment test found at eccstudent. (passcode: acls15). You are encouraged to take the test until you score 84%.
• Print the results to bring to class. Cannot attend without pre-test!
• $40 check/money order (textbook).
• $260 check/money order (course fee).
• $300 total (can be paid with one check to Cone Health). Credit card option coming soon!
A confirmation email will be sent and your textbook will be mailed within 2 weeks to the address below.
Name: _______________________________________________________________
Job Title: _____________________________________________________________
Street Address: ________________________________________________________
City: _________________________ State: _______ Zip: ____________
Phone number
Work: _______________ _____Home: ____________________
Cell: _____________________
Email address: __________________________________________________
Date of class: 1st choice: _____________ 2nd choice: __________________
Initial class _____ or Renewal _____
Please contact Rob Emory if you have any questions at 336-832-7387 or
rob.emory @
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