Basic Life Support (BLS) 2012 - Bon Secours Charity Health System
Basic Life Support (BLS) 2012 - Bon Secours Charity Health System
Basic Life Support (BLS) 2012 - Bon Secours Charity Health System
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REGISTRATIONFORM<strong>Basic</strong> <strong>Life</strong> <strong>Support</strong> (<strong>BLS</strong>)Provider Course<strong>2012</strong>*** PLEASE PRINT all information CLEARLY ***Please Tell Us About You:Unit:Your Hospital:Name:Address:CityState, ZipPhone Numbers:Home:Cell:Work:Email:Job Title:Which Class Would You Like To Take?Date of Course:Time:Payment Enclosed: (If Applicable)PDE Dept Use ONLY:Card Expiration Date: _____________________Verified By:______________________________Date Verified: ____________________________HOSPITAL ADDRESSES:<strong>Bon</strong> <strong>Secours</strong> Community Hospital168 East Main St.Port Jervis, NY 12771845-858-7000Good Samaritan Hospital255 Lafayette Ave.Suffern, NY 10901845-368-5000St. Anthony Community Hospital15 Maple Ave.Warwick, NY 10990845-986-2276The American Heart Association strongly promotes knowledgeand proficiency in <strong>BLS</strong>, ACLS, and PALS and has developedinstructional materials for this purpose. Use of these materials inan educational course does not represent course sponsorship bythe American Heart Association. Any fees charged for such acourse, except for a portion of fees needed for AHA coursematerials, do not represent income to the Association.<strong>BLS</strong> - ProviderAMERICANHEART ASSOCIATIONBASICLIFE SUPPORTPROVIDER COURSE<strong>2012</strong>Professional Development and Education(845) 368 – 5000 Ext. 6791
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