Www.healtheducatorsinc.com



Health educators, inc. 2009

2009 PALS – HCA Registration Form

PLEASE PRINT

|PARTICIPANT Information |

|First Name | |Last | |M.I. | |Date | |

|Street Address | |Apartment/Unit # | |

|City | |State | |ZIP | |

|Home Phone | |Work Phone | |

|Cell Number | |Email address | |

|*3-4 user ID |- |*Cost Center | |*Department | |

|Hospital |HDH-Forest |HDH-Parham |CJW-Chip |CJW-JW |JRMC |Retreat |Hanover Outpt |Tuckahoe Surgery|

| | | | | | | | |Ctr |

|Job Title |MD |PA |RN |RT |LPN |Paramedic |Other: |

|Class Information |

|Please check the calendar on our website for class availability - |

|Time |9 a.m. to 6 p.m. |Place |Northgate Centre – 8010 Staples Mill Rd., Richmond, VA 23228 |

|RENEWAL DATES: (* attach copies of your current PALS and CPR cards) |

|Jan 9 – Fri |

|Jan 21 (Wed) & Jan 23 (Fri) |May 1 (Fri) & May 2 (Sat) |Sep 28 (Mon) & Sep 29 (Tu) | |

|Feb 6 (Fri) & Feb 7 (Sat) |Jun 3 (Wed) & Jun 5 (Fri) |Oct 12 (Mon) & Oct 14 (Wed) | |

|Mar 5 (Th) & Mar 6 (Fri) |Jul 6 (Mon) & July 8 (Wed) |Nov 6 (Fri) & Nov 7 (Sat) | |

|Apr 1 (Wed) & Apr 3 (Fri) |Aug 3 (Mon) & Aug 5 (Wed) |Dec 2 (Wed) & Dec 4 (Fri) | |

|1st Choice: | |2nd Choice: | |

|Nurse Manager or Director information |

|*Nurse Manager’s Email | |

|*Nurse Manager’s Fax | |*Nurse Manager’s Phone | |

|*Nurse Manager’s or | |

|Director’s Signature | |

* Required

Please fax or mail your request to:

(Confirmation will be faxed or emailed to you within 48 hours - if you don’t receive a confirmation please call our office)

Health Educators, Inc., 8010 Staples Mill Rd., Richmond, VA 23228

Phone: (804) 553-0460; Fax: (804) 553-0463

Email: healtheducators@ Website:

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