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Course Registration Form

Don't forget to PAY for your course after you REGISTER. You may do both online or via mail. On the Courses Offered Page, you will find a link for course information and you can add course(s) to your cart to pay with Paypal (you do not need a Paypal account). You may also mail a personal check, cashier's check, money order, or Company PO.  No Cash Please! 
**If mailing payment, please press the white PRINTER FRIENDLY button (at the bottom of the form) and then fill out the form, print the form and remit with payment.

No refunds. Courses missed may be rescheduled. Pre-Course materials are mailed 7 - 14 days prior to course beginning. Not responsible for items lost or damaged during shipping.

Select Classes

BLS Instructor February 5, 2009
ACLS Instructor February 6, 2009
DOT EMT Refresher February 7-8, 2009
DOT Paramedic Refresher February 7, 8 & 14, 15, 2009
PALS Instructor February 13, 2009
ACLS Initial March 19, 2009
ACLS Renewal March 19, 2009
PALS Initial March 20, 2009
ACLS Initial May 21, 2009
ACLS Renewal May 21, 2009
PALS Initial May 22, 2009
ITLS Provider June 9-10, 2009
ITLS Pediatric June 11, 2009
ACLS Initial August 7, 2009
ACLS Renewal August 7, 2009
PALS Initial August 8, 2009
ACLS Initial October 15, 2009
ACLS Renewal October 15, 2009
PALS Initial October 16, 2009
DOT EMT Refresher November 7-8, 2009
DOT Paramedic Refresher November 7, 8 & 14, 15, 2009
ITLS Pediatric December 2, 2009
ACLS Initial December 11, 2009
ACLS Renewal December 11, 2009
PALS Initial December 12, 2009

NAME    First   Last

 * required

Home Phone
(xxx) xxx-xxxx

 * required

Work or Cell Phone
(xxx) xxx-xxxx

 * required

Email address

 * required

MAILING Address
This is where pre and post course documents will be mailed.
If you move, please let us know your new address ASAP.

 * required

City, State Zip

 * required

Gender   M OR F

 * required

DATE OF BIRTH   MM/DD/YYYY

 * required

Employer

 * required

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

 * required

Certification or
Licensure Level
(MD, PA, RN, NP, EMT-B, EMT-IV, EMT-P, First Responder, etc)

 * required

State of Licensure     
(2 letter abbrev.)

 * required

State License Number

 * required

State License Expiration Date

 * required

National Registry Number

National Registry Expiration

Please update via Email on future Benchmark courses and events.
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The American Heart Association 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 successful demonstration of the core knowledge on said date and neither guarantees nor implies whether implicitly or explicitly a guarantee of successful future performance. The Training Center, Facilitator, Coordinator and or Instructor(s) do not guarantee future performance. Therefore, by participating in this activity, the participant hereby indemnifies and holds the aforementioned harmless from any claims as may arise from participation in this activity or activities. The participant furthermore agrees and understands that comprehension and performance is an individual responsibility, and that the sponsoring organization does not license or certify individuals in skills or procedures. The participant must adhere to local standing orders, protocols, or other medical direction, and within the individual's scope of practice.

PRIVACY NOTICE: Submission of information will be retained for course attendance, participation and reporting as may be required bu the course sponsor and or distributor of continuing medical education hours 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 clicking the submit button above, or printing and mailing the form, you attest that you have read and agree to the course completion policy, the privacy notice and you have submitted to the best of your knowledge correct and true information. Furthermore, you 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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