CPR Registration Form - UMBC Department of Emergency Health ...

HEARTCODE PALS
PARTS I & II
Sunday, November 16, 2014 ~ 9 am – Noon
All registrations must be faxed or postmarked by November 2, 2014.
All PALS Courses at the University of Maryland, Baltimore County are taught according to the standards of the
American Heart Association, Maryland Affiliate, Inc.
Continuing Education Credit: This continuing education activity is approved by UMBC, an organization accredited by the Continuing Education Coordinating
Board of Emergency Medical Services (CECBEMS). EMS providers must provide both NREMT # and expiration date (if applicable) and state license and
expiration date to receive CECBEMS credit.
A valid CPR card is required to take this course and must be presented with your registration form. Your
CPR card & Certificate of Completion MUST be presented you when you come to do your skills check out.
Please type or print clearly. A confirmation packet will be sent upon receipt of registration and payment.
You may fax your registration form with credit card information to (410) 455-6713.
OR
Mail this completed form and your check made payable to "UMBC" to:
UMBC – Department of EHS/PACE
1000 Hilltop Circle, Academic IV – A Wing – Room 316
Baltimore, Maryland 21250
Name:
Email:
Address:
City, State, Zip:
Phone:
Alternate Phone:
NREMT-P #:
Exp. Date:
EMT-P,RN, MD License #: State: Exp. Date:
Enter Amount
11/15/14 HeartCode PALS Course – Pts. I & II $200.00
I wish to purchase a PALS Provider Manual $ 43.00
Enclosed is my check in the amount of >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Credit Card Convenience processing fee (add to balance above) $ 5.00 $ 5.00
Please charge my VISA MasterCard Discover (please circle one) >>>>>>>>
Card
Number:
Billing
Address
V-Code:
(last three digits on back of card)
Name as it appears on
Card:
Signature:
Expiration Date:
Cancellations/Refunds
All registration fees are non-refundable. Registrants may transfer to another course one time (within one year of initial registration) for an additional fee of $45.00.
A $45.00 fee will be charged for any returned check.
UMBC reserves the right to cancel any course due to insufficient enrollment. Tuition will be refunded or transferred to another course date at UMBC's expense.
“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.”
I understand that if I have not provided complete state license and NREMT (if applicable) information that I may not receive credit for this course.
Signature: ________________________________________________
I have read and understand the cancellation/refund policy.
Signature: ________________________________________________
For Office Use Only
T-Code: 410 Fund Code: 1113 Prog Fin: 000 Department: 10556 Account: 4873372 Project: CV390043 Actv ID: CNV
Resc Type: OPREV
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HEARTCODE PALS
PARTS I & II
Onsite check out @UMBC
Sunday, November 16, 2014
9:00 am - Noon
Information Sheet
1. Part 1 is on CD only. Each CD issued will be good for use on only one (1)
computer for only one (1) use.
2. PC only, will not work on Macs.
3. A valid CPR card is required to take this course and must be presented with
your registration form. You must also bring your CPR card with you when you
come to do your skills check out.
4. You must bring the certificate of the successful completion of the CD portion of
the course with you when you come to complete the skills check out.
WITHOUT THE PART 1 CERTIFICATE OF COMPLETION, you will not be allowed
to complete the skills check out.
5. Successful completion of this CE activity includes the following:
o Complete the CD program and the UMBC on-site test.
o Print Certificate/Statement of Credit.
o Complete the written exam and skills check out at UMBC.
o Complete the course evaluation form.
6. After successful completion of the items above, UMBC will process the course
roster and issue a PALS course card. This card will be mailed to the address
provided on the registration form approximately four (4) weeks after the
course conclusion.
7. This course is recommended for renewal of a current PALS certification. It is
not recommended for those that have not previously taken a PALS course.
8. The on-site check out is for skills testing only. You must come prepared. You
will not have time to practice skills prior to testing.
9. This continuing education activity is valid for 12 hours.
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