EFL

Education For Life

ACLS

Registration Form

****IMPORTANT****

****PLEASE READ ENTIRE REGISTRATION FORM****

v To Register for Classes complete this registration form remember to write in class dates requested.

v Required Text is the 2005 ACLS Provider Manual and Study Guide, AHA requires that you bring the text to class.

v If renewing include a photocopy of your current ACLS card and attach it to the registration form. Renewal registrations without verification of a current ACLS card will be returned. There is no grace period, your current card outdates by the end of its expiration month.

v BLS is essential for the class and your skills will be tested as part of the curriculum.  Please come prepared.

v Course materials including textbooks, if ordered and map will be mailed upon receipt of completed registration form, payment of tuition, and if renewing copy of ACLS card.  Please allow one week for delivery.  Make Checks Payable to Education For Life, Send completed form to: PO Box 1635, Hillsboro OR.  97123     Phone 503-693-3352

 CHECK ALL THAT APPLY:

Requested Course Date:

Course Fee (Non Contract) o $150.00   Initial o $105.00   Renewal o $  38.00   Textbook o $  18.00   ECC Handbook

Course Fee (Contract) o $130.00  Initial o $  95.00   Renewal o $  38.00   Textbook o $ 18.00   ECC Handbook

***COMPLETE ALL FIELDS – REQUIRED***

EMPLOYER DEPARTMENT MD   RN(circle one)            Other please specify

NAME: LAST                                                          FIRST                                                       MI

ADDRESS                                                         CITY                             STATE                      ZIP

EMAIL                                                                                               PHONE #

Refund Policy:  All registrations must reach Education for Life 10 days prior to class date.  Registrations

received after that date will be charged a $50 late fee payable by Visa, Master Card, or Money Order. 

Cancellations received 10 days prior to class will receive a refund less a $50 cancellation fee. 

No refunds after the 10-day cut off. NO EXCEPTIONS.