Heartsaver (HS):



REGISTRATION FORM – PRINT CLEARLY

If you cannot attend as scheduled, you MUST contact the CLSE to arrange a new date and time. Failure to do so 24 hours prior to the course will forfeit tuition.

| |

|NAME | Dpt/Facility |

|ADDRESS |

|CITY, STATE, Zip |HOME PHONE |WORK PHONE |

| | | |

|Email: MANDATORY. (Mandatory in case of class cancellation or weather!) |

| |

| |

|CHS Employee? |New Hire? |CCHS Student? |

|□ YES □ NO |□ YES □ NO |□ YES □ NO |

| |

|Course Type: (check one) | |Course Date: |

| |□ BCLS Instructor $200 | |

|□ BLS Online Part 2 |□ ACLS Instructor Only $200 | |

|□ BCLS Traditional (8:00 – 1:00) |□ PALS Instructor Only $200 | |

|□ ACLS | | |

|□ PALS □ PALS Re |□ ACLS & PALS Instructor Combo | |

|□ ECG □ ACLS Re |$325.00 | |

| | |Course Time: |

|((Mandatory: Current Provider Card & Text for ALL Renewal Courses(( |

|Check enclosed. Specify amount: $ _________(Carolinas College of Health Sciences) |

| |

|Credit card. Specify amount: $ _________________ (PRINT CLEARLY) |

| |

|Account #: |

|Exp. Date: |Signature |

|/ | |

| | | | |

|Visa □ |MasterCard □ |American Express □ |Discover □ |

| |

|Interdepartmental charge (PRINT CLEARLY) 10 DIGIT NUMBER MANDATORY |

|Cost Center: |Acct#: |Manager Signature: |

| |631500 | |

|Check One: |

|Pick Up Course Materials |Receipt Needed? |

|Mail Materials to Address Above |Send Materials Via Interoffice Mail |

Submit Registration Form by fax 704-355-9293; scan and email to christy.dull@; or mail to the

Center for Life Support Education, 1200 Blythe Blvd, Suite 220, Charlotte, NC 28203

[pic] Reimbursement:

Carolinas Healthcare System

Center for Life Support Education

Basic Life Support for HealthCare Providers (BCLS)

Advanced Cardiac Life Support (ACLS)

ECG for ACLS

Pediatric Advanced Life Support (PALS)

BCLS, ACLS, and PALS Instructor Courses

Center for Life Support Education

1200 Blythe Boulevard

Charlotte, NC 28203

Fax: 704-355-9293

christy.dull@

For BCLS, you can choose ONE of two methods:

1. Basic Life Support for the HCP Traditional Classroom: $60.00 (8:00—1:00) (Provider & Renewal) Textbook included. This course is designed for healthcare professionals or students required to have Healthcare Provider CPR.

OR

2. BCLS Online Part 1 and Part 2: (1:00—3:00) – No Textbook

A. Online Part 1: $22.00 (PAY ONLINE DIRECTLY TO WEBSITE)—

Access the American Heart Association website by typing in the web address: and choose BLS Online Part 1 program. Complete Part 1. The test has to be completed in one sitting. Print the ‘Course Completion Certificate’ and bring to Part 2.

B. Online Part 2 Skills Check: $25.00 (Register via Brochure; PAY TO CCHS)

You must bring the ‘Course Completion Certificate’ (Passing) to BLS Online Part 2. Be ready to check off on all BLS Skills. Complete skills check (Part 2) within 60 days of completion of BLS (Part 1).

Advanced Cardiac Life Support (ACLS-P): $140.00

Participants must hold current BLS Healthcare Provider certification. ACLS textbook included. 1st Day: 8:00-4:00; 2nd Day: 8:00-1:00

Advanced Cardiac Life Support Renewal (ACLS-Re): $140.00

Must hold current BLS and ACLS provider status. ACLS textbook included. 8:00-5:00

Pediatric Advanced Life Support (PALS-P): $140.00

Participant must hold current BLS Healthcare Provider certification. PALS textbook included. 1st Day: 8:00-4:00; 2nd Day: 8:00-1:00

Pediatric Advanced Life Support Renewal (PALS-Re): $140.00

Must hold current BLS and PALS provider status. PALS textbook included. 8:00-5:00

BCLS, ACLS, or PALS Instructor: Must be CHS Employee

Current provider card is mandatory. Instructor and Provider texts included. Instructor classes require Pre-Work (Instructor Essentials Course) prior to class. Essentials information will be forwarded to you by email once registration and payment has been received. Class Breakdown:

√BCLS Instructor, ACLS Instructor and PALS Instructor Only: $200 each

√ACLS & PALS Instructor Combo: $325 (Includes both sets of texts & Essentials)

ECG for ACLS: $90.00

This course does not take place of ACLS. ECG for ACLS text included. No pre-requisites. Course covers dysrhythmia recognition and is recommended prior to ACLS provider course for those who need additional assistance identifying rhythms. Class time 8:00-3:00

(ECG for ACLS

|07/27/15 |CON 066 |8:00—3:00 |Monday |

| | | | |

(BCLS Provider Courses: Traditional Class 8:00—12:00

|04/29/15 |CON 060 |8:00-1:00 |Wednesday |

|05/13/15 |CON 060 |8:00-1:00 |Wednesday |

|06/24/15 |CON 060 |8:00-1:00 |Wednesday |

|07/29/15 |CON 060 |8:00-1:00 |Wednesday |

( CCHS STUDENTS ONLY!** BCLS Online Part 2 Skills: (Must Complete Online Part 1 First)

|**06/05/15 |Part 2 |8:00 – 11:00 |Friday |

|**06/26/15 |Part 2 |8:00 – 11:00 |Friday |

|**07/17/15 |Part 2 |8:00 – 11:00 |Friday |

|**12/11/15 |Part 2 |8:00 – 11:00 |Friday |

|**12/17/15 |Part 2 |8:00 – 11:00 |Thursday |

(BCLS Online Part 2 Skills Check: 1:00—3:00 (Must Complete Online Part 1 First)

|04/01/15 |Part 2 |1:00 – 3:00 |Wednesday |

|04/08/15 |Part 2 |1:00 – 3:00 |Wednesday |

|04/15/15 |Part 2 |1:00 – 3:00 |Wednesday |

|04/22/15 |Part 2 |1:00 – 3:00 |Wednesday |

|04/29/15 |Part 2 |1:00 – 3:00 |Wednesday |

|05/06/15 |Part 2 |1:00 – 3:00 |Wednesday |

|05/13/15 |Part 2 |1:00 – 3:00 |Wednesday |

|05/20/15 |Part 2 |1:00 – 3:00 |Wednesday |

|05/27/15 |Part 2 |1:00 – 3:00 |Wednesday |

|06/03/15 |Part 2 |1:00 – 3:00 |Wednesday |

|06/10/15 |Part 2 |1:00 – 3:00 |Wednesday |

|06/17/15 |Part 2 |1:00 – 3:00 |Wednesday |

|06/24/15 |Part 2 |1:00 – 3:00 |Wednesday |

|07/01/15 |Part 2 |1:00 – 3:00 |Wednesday |

|07/08/15 |Part 2 |1:00 – 3:00 |Wednesday |

|07/15/15 |Part 2 |1:00 – 3:00 |Wednesday |

|07/22/15 |Part 2 |1:00 – 3:00 |Wednesday |

|07/29/15 |Part 2 |1:00 – 3:00 |Wednesday |

|08/05/15 |Part 2 |1:00 – 3:00 |Wednesday |

|08/12/15 |Part 2 |1:00 – 3:00 |Wednesday |

|08/19/15 |Part 2 |1:00 – 3:00 |Wednesday |

(ACLS Provider Courses:

|04/21/15—04/22/15 |CON 062 |8:00-5:00 |Tues/Wed |

|05/21/15—05/22/15 |CON 062 |8:00-5:00 |Thurs/Friday |

|06/02/15—06/03/15 |CON 062 |8:00-5:00 |Tues/Wed |

|08/18/15—08/19/15 |CON 062 |8:00-5:00 |Tues/Wed |

(ACLS Renewal Courses: -- Current Card Only!

|05/11/15 |CON 063 |8:00-5:00 |Monday |

|07/21/15 |CON 063 |8:00-5:00 |Tuesday |

(PALS Provider Courses:

|05/05/15—05/06/15 |CON 064 |8:00-5:00 |Tues/Wed |

|07/14/15—07/15/15 |CON 064 |8:00-5:00 |Tues/Wed |

(PALS Renewal Courses: -- Current Card Only!

|04/01/15 |CON 065 |8:00-5:00 |Wednesday |

|06/30/15 |CON 065 |8:00-5:00 |Tuesday |

(Instructor Courses: (Must be a CHS Employee)

|BCLS Instructor |8:00 – 5:00 |05/12/15 |Tuesday |

|BCLS Instructor |8:00 – 5:00 |08/06/15 |Thursday |

|ACLS & PALS Instr. Combo** |8:00 – 5:00 |04/28/15 |Tuesday |

|ACLS & PALS Instr. Combo** |8:00 – 5:00 |08/04/15 |Tuesday |

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[pic]For CCHS’ inclement weather message call the Weather Hotline at 704-446-7854.

School closings and delays are posted on Channel-9.

Voice Mail 704-355-5699.

It is strongly recommended that you register and have the materials at least a week prior to the class. Materials must be received/picked up at least one week prior to the class.

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