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Course Registration Form

BLS for Healthcare Provider (CPR), ACLS, or PALS courses, are required to obtain the appropriate American Heart Association textbook from the South College library 7 - 14 days prior to the date of the course for which you are registering. 

ACLS and PALS textbooks contain inside the front cover, a DVD  with pre-course work.  This must be completed in its entirety, a minimum score of 84% attained (you may repeat as many times as necessary),   and the results printed and submitted upon entering the first day of class. Participants not presenting with the printed results pages will not be allowed to participate in the course. No other form of pre-test is acceptable.

BLS Healthcare Provider (CPR) course preparation is required. The BLS text contains a pre-course DVD deomonstrating the skills using the new guidelines. 

TEACH textbooks are handled differently. You will receive a confirmation email and pre-course letter after we receive your registration form. The letter will provide all details of the course.

No refunds. Courses missed may be rescheduled. Benchmark is not responsible for items lost or otherwise in the mail system.

Select Class(es)

Heartsaver Courses

Heartsaver AED w/ CPR, 15 OCT 201020 9a - 11a

BLS (CPR) for Healthcare Providers

BLS (CPR) Healthcare Provider, 06 AUG 2010 1pm - 5:30pm
BLS (CPR) Healthcare Provider, 18 AUG 2010 1pm - 5:30pm (M.A)

Advanced Cardiac Life Support (ACLS)

ACLS Provider, 16 - 21 AUG 2010 (PA)

Pediatric Advanced Life Support (PALS)

PALS Provider, 23-28 AUG 2010 (PA)

NAME         First             MI             Last
Please enter name as it appears on your professional or state driver license.

 * required

Home Phone
(xxx) xxx-xxxx
Do not use cell phone for the home number. If you use cell as home, please enter n/a here.

 * required

Work or Cell Phone
(xxx) xxx-xxxx

 * required

Email address
It is preferable for you to NOT use a school email address as some school spam programs prevent passage of important email notifications. 

 * required

Home Mailing Address

 * required

City, State, and Zip Code

 * required

Gender   M or F

 * required

DATE OF BIRTH   MM / DD / YYYY

 * required

Employer
Please enter Student if not employed.

 * required

South College Program in which you are enrolled.
(PA, RN, RT, PT, MA, etc)

Certification or
Licensure Level

(MD, PA, RN, NP, EMT-B, EMT-IV, EMT-P, First Responder, etc)
Enter "n/a" if not currently certified or licensed as a healthcare provider.

State of Certification or Licensure     
(2 letter abbrev.)
Enter "n/a" if not certified or licensed as a healthcare provider.

State Certification or License Number
Enter "n/a" if not certified or licensed as a healthcare provider.

State Certification or License Expiration Date
Enter "n/a" if not certified or licensed as a healthcare provider.

Please read the disclaimers below prior to pressing the submit icon.
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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. This neither implicitly nor explicitly guarantees any degree of future performance. Therefore, by participating in this activity, the participant hereby indemnifies and holds the Training Center, its Faculty, Staff, assistants, and agents thereof harmless 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, 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 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 does not disclose, sell, or trade, and protects registrant personal information 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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