INVOICE - Illinois ENA



Pretesting 21 November 2019 and Instructor Course 22 November 2019

Northwestern Medicine-Central DuPage Hospital

NOTE: Only fully completed applications will be considered. Applications will be accepted until the course is full.

All Instructor Potentials must confirm their attendance 4 weeks prior to the course to allow those on the waiting list the opportunity to plan and receive materials in the event there is an opening.

Application deadline: __ 18 October 2019______________________________________________________________________

Send to: AMITA St. Alexius Medical Center

ATTN: EMS/Trauma Department Karin Buchanan

1555 Barrington Road

Hoffman Estates, IL 60196

Applicant Name:

Address:

Preferred Phone 1 (Cell/Home/Work [circle one]): __________ / __________—______________

Preferred Phone 2 (Cell/Home/Work [circle one]): __________ / __________—______________

Preferred Email 1 (Home/Work [circle one]):

Preferred Email 2 (Home/Work [circle one]):

RN License No/State:

Date of Provider Course Attended:

Course Director:

Location of Provider Course:

PLEASE INCLUDE THE FOLLOWING WITH YOUR APPLICATION:

□ Copy current nursing license

□ Copy current TNCC provider card

□ Letter indicating instructor potential/instructor path from Provider Course Director (the Course Director of the course you received your provider card).

□ Letter supporting your potential to be a successful instructor (may be written by a professional colleague)

□ Name of possible instructor mentor

1. Employment Experience (please list current position first and include dates of employment):

2. Professional Experience (particularly related to trauma):

3. Education (basic preparation through highest degrees held):

4. Provide a statement expressing commitment to and interest in teaching future TNCC courses:

Notification of acceptance into the instructor course will occur by October 18 via email. Instructions, assignments, and hotel information will be sent with that email. Pre- Course and Course will be held at

Northwestern Medicine-Central DuPage Hospital

25 N. Winfield Road

Winfield, IL 60190

Please forward the application to:

Karin Buchanan

AMITA Health St. Alexius Medical Center

1555 Barrington Road

Attn: EMS/Trauma Department

Hoffman Estates, IL 60196

Or fax to 847-781-3913, attention Karin Buchanan, or e-mail scanned documents to Karin at Karin.Buchanan@

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8th Edition

Instructor Potential/PATH Application

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