2012 BLS/First Aid Initial Instructor Course CoxHealth Education ...

2012 BLS/First Aid Initial Instructor CourseCoxHealth Education Center, Orientation Classroom3801 S. National, Springfield, MO 65807FacultyBeth Keith, MS, CHESTraining Center Coordinator, BLS Regional FacultyCoxHealth Education Center, Springfield, MOAmber ClarkBLS Training Center FacultyCoxHealth Education Center, Springfield, MOWe reserve the right to substitute educators.Dates (registration page attached)Thursday, January 12, 8am - 4:30pmTuesday, April 10, 8am - 4:30pmTuesday, June 5, 8am - 4:30pmFriday, July 27, 8am - 4:30pmTuesday, October 2, 8am - 4:30pmThursday, November 29, 8am - 4:30pmRegistration closes 2 weeks prior to each date. Please call if needed.Target Audience and CriteriaThis course is designed to prepare instructors to teach providers Basic Life Support(BLS) and Basic First Aid techniques recommended by the American Heart Association(AHA). This course will transition those certified in Basic Life Support for HealthcareProviders to a BLS Instructor.Pre-requisites – All 3 must be completed before entry into the course1. Copy of your current AHA “BLS for Healthcare Providers Card” ( front & back)2. Letter of recommendation (from supervisor, another instructor, or someonewho has knowledge of your teaching ability)3. Please contact the TC Coordinator prior to registration, Beth Keith, (417/269-4150 or elizabeth.keith@coxhealth.com) to affiliate with the CoxHealth TrainingCenter. You must be pre-approved.Steps to becoming a BLS Instructor after registration is complete1. You will receive a pre-course program called the “Instructor Core Course”(CD/Online format) in the mail 2 weeks prior to the date of this course. You willbe expected to complete this before entry into the live course. You will not bepermitted to enter the live course if you have not completed the pre-courseprogram.2. You will attend the live course of your choice (registration on next page).3. You will make an appointment to be monitored within 90 days after the course.Arrangements made at the live course. NOTE: You must be monitored beforeteaching your first course. Please do not schedule courses until after you haveattended your instructor course.Registration Fee, Cancellation, andRefund PolicyCourse Fee – TOTAL FEE is $350.00Fee BreakdownLive Classroom Fee$250.00 for non-Cox employees; $100.00 forCox employees. Please make checks payable toCoxHealth. Call 417/269-4117 to pay by creditcard.Training Center Membership Fee:CoxHealth Training Center (TC) assesses a$100.00 TC membership fee for the two-yearBLS instructorship period. This fee is to be paidat the time of the BLS Instructor Course andmust be paid biannually to remain affiliated withthe CoxHealth TC. No fee for CoxHealthemployees.Cancellations and RefundsCancellations up to 72 hours prior to the course will beentitled to a full refund. After this time, a $25processing fee will be withheld. No refunds will bemade after the program begins. Program concernsmay be addressed to CoxHealth Educational Servicesat 417-269-4117 or via email ateducation@coxhealth.com. Participants are entitled toa full refund if the provider cancels or reschedules theactivity, or the participant may transfer registration tothe next scheduled activity. Refunds will be providedwithin 4-6 weeks in the form of a check mailed to theaddress from which the payment was received. Creditcard payments will be credited to the same paymentinformation obtained at the time of registration. Thiscancellation procedure applies to all attendees,regardless of method of payment.Americans with Disabilities Act: If you have specialneeds addressed by this act, please give at least twoweeks notice before this offering. Reasonable effortswill be made to accommodate your needs.Please Note: CoxHealth and all of its facilities andgrounds are tobacco free.Please bring a sweater or jacket due to variations intemperature and personal preferences.For questions:Contact Beth Keith, 417/269-4150, Elizabeth.Keith@CoxHealth.com or EducationalServices at 417/269-4117 or via email at education@coxhealth.com.

2012 BLS/First Aid Initial Instructor CourseCoxHealth, Educational Services, 3801 S. National, Springfield, Mo. 65807Space is limited to 16 students per class. Register early!STEP 1: ATTENDEE INFORMATIONPlease print all information so we can notify you of any changes. Please complete all requested information. Incompleteregistration forms will not be processed.Name:Home address:CoxHealth department/Place of employment:Title/Position:E-mail address:We do not sell contact information.Last First MIStreet City State ZipDaytime phone:STEP 2: SELECT DATEAll courses are held in the Orientation Classroom, Educational Services, Cox South Thursday, January 12, 8am - 4:30pm Tuesday, April 10, 8am - 4:30pm Tuesday, June 5, 8am - 4:30pm Friday, July 27, 8am - 4:30pm Tuesday, October 2, 8am - 4:30pm Thursday, November 29, 8am - 4:30pmSTEP 3: REGISTRATION FEEPlease check the appropriate payment below. $350 for non-CoxHealth employees $100 for CoxHealth employeesSTEP 4: INDICATE METHOD OF PAYMENT Master Card VISA DiscoverName on credit/debit card (if different from above):Billing address (if different from above):Registration received without payment will not be processed.Credit/Debit Card number: .Expiration Date: / Three Digit Security Code (on back of card): ____ ____ ____Cardholder signature(required): ___________________________________________________________________ Check enclosed (payable to CoxHealth) Cash (cash only accepted in person at the Educational Services Main Office) GL Transfer (Cox employees must have manager approval to select this option)GL Number:__________________________________________ Manager Phone number:_____________________Manager Signature (required):______________________________________________________________________STEP 5: RETURN REGISTRATION AND PAYMENTReturn completed registration form and payment to:CoxHealth Educational Services ▪ 3801 S. National Ave. ▪ Springfield, MO 65807 ▪ Fax: 417/269-4787For Educational Services Office Use Only:Date received: ___/___/___ Date entered: ___/___/___ Processed by:_______________________________________The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use ofthese 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 offees needed for AHA course materials, do not represent income to the Association.