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Course Registration Form

Please ensure payment is submitted with registration form.

ONLINE Registration and Payment is a TWO-STEP process:  1) Go to the Courses Offered page and add the course(s) to your cart and complete the secure online payment process via PayPal (no PayPal account required). 2) Return to this page, complete then submit this registration form.

Registration and Payment submitted via Mail:  Please press the white PRINTER FRIENDLY button (at the bottom of the form) THEN complete the form, print the form, and remit with payment. Payments may be made using personal check, cashier's check, money order, or Company PO, and USD only.

Class Location:  Karns Fire Department Station #1, 6616 Beaver Ridge RD, Karns, TN  next to the Karns Lions Community Park.  

Each class block is scheduled for 4.0 Contact Hours.  These  contact hours may be converted to up to 0.4 CEU per class for First Responders, EMTs, and Paramedics.  The all-inclusive fee for each module is only $20.00 per person.

Lead Instructors: Ronnie D Patterson and John S Holloway.

Please contact us if you need housing information or travel directions.

These continuing education activities are approved by Benchmark Medical Services, LLC, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS). CECBEMS is the national accrediting body established to develop and implement policies to standardize the review and approval of EMS continuing education activities. For additional information on CECBEMS, go to www.cecbems.org.

No refunds. Courses missed may be rescheduled. Benchmark is not responsible for items lost or damaged during shipping.

Select Classes

 

You only need to attend one day for each module.


Patient Assessment
Module III, August 25, 2009, 1800-2200hrs
Module III, August 30, 2009, 1330 - 1730 hrs
Trauma Emergencies & Trauma Destination
Module IV, October 20, 2009, 1800-2200hrs
Module IV, October 24, 2009, 0800-1200hrs

Skills Assessment: First Responder & EMT

Module V, December 12, 2009, 0800-1700hrs
Module V, December 13, 2009, 0800-1700hrs

NAME as it appears on your certification or license

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Home Phone
(xxx) xxx-xxxx
Do not enter cell or work as home

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Work or Cell Phone
(xxx) xxx-xxxx
Do not use home for work or cell number.

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Email address
Our primary means of communication is via email. Please enter an email address you will check often and ensure you set your spam controls to allow emails from benchmarkems@bellsouth.net.

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Home Mailing Address

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City, State, and Zip Code

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Gender   (M or F)

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Date of Birth   (MM / DD / YYYY)

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Employer

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Assignment / Department / Shift
(unit, nights, truck, etc)

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Level of Certification or
Licensure

(MD, PA, RN, NP, EMT-B, EMT-IV, EMT-P, First Responder, etc)

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State of Licensure     
(2 letter abbrev.)

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State Certification / License Number
Please omit the 0's in front of the numbers.
Please ensure you enter your Certification or License Number and not your renewal number.

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State Certification / License Expiration Date

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National Registry Number
Enter "n/a" if not applicable.

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National Registry Expiration
Enter "n/a" if not applicable.

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Method of Payment

Online Credit/Debit Card via PayPal
Check, Cashier's Check or Money Order
Company Purchase Order

Before clicking the submit link below, please read the information below this form.

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AHA DISCLAIMER:  The American Heart Association (AHA) strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association. Any fees charged for such a course, except for a portion of fees needed for AHA course materials, do not represent income to the Association.

COURSE COMPLETION: Course completion is defined as: The participant successfully demonstrated the core knowledge on said date and Benchmark, its faculty, staff, assistants, and agents neither implicitly nor explicitly guarantees any degree of future performance. Therefore, by participating in this activity, the participant hereby indemnifies and holds harmless Benchmark, its faculty, staff, assistants, and agents from any claims that may arise from participation in this activity or activities. The participant furthermore agrees and understands that comprehension and performance is an individual responsibility; that Benchmark does not license or certify individuals in skills or procedures; and that the participant must adhere to local standing orders, protocols, or other medical direction, and within the individual's scope of practice.

COURSE COMPLETION DOCUMENTATION REPLACEMENT POLICY:  Post Course documentation is mailed via U.S. Post Office to the address entered during registration. Post course documentation is presumed to have been received unless returned by the U.S. Post Office. If returned by the U.S. Post Office, the documents will be held until you contact us. A replacement fee of $25.00 per document will be assessed for any reason other than an error on our part. 

PRIVACY NOTICE: Submission of information will be retained for course attendance, participation and reporting as may be required by the course sponsor and or distributor of continuing medical education certificates. This information may be used to notify the participant of future licensure / certification or continuing education or training opportunities. Benchmark protects the registrant personal information as protected under HIPPA, protecting against public inspection absent a subpoena or for the purposes of health oversight activities as described herein.

SUBMISSION: By submitting registration information and participating in the registered course, you attest that you have read, understand, and agree with the course disclaimers, terms, and conditions, and that you have submitted to the best of your knowledge correct and true information. You also acknowledge that it is your responsibility to notify Benchmark in the event of any change in information within thirty days of such change.

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