Health Educators, Inc

hEALTH EDUCATORS, INC. 2009

2009 ACLS – Registration Form (BSR employees only)

PLEASE PRINT

PARTICIPANT Information

First Name / Last / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Home Phone / Work Phone
Cell Number / Email address
*Cost Center / - / *Department
Hospital / SMH / SFMC / MRMC / RCH / VHS / Other
Job Title / MD / PA / RN / RT / LPN / Paramedic / Other:

Class Information

Please check the calendar on our website for class availability - www.healtheducatorsinc.com
Time / 9 a.m. to 6 p.m. / Place / Northgate Centre – 8010 Staples Mill Rd., Richmond, VA 23228
RENEWAL DATES: (* attach your current ACLS and CPR cards)
Jan 10- Sat / Mar 14- Sat / May 9- Sat / July 11- Sat / Sept 12- Sat / Nov 11- Wed
Jan 16- Fri / Mar 16- Mon / May 15- Fri / July 13- Mon / Sept 18- Fri / Nov 14- Sat
Jan 19- Mon / Mar 20- Fri / May 18- Mon / July 17- Fri / Sept 21- Mon / Nov 16- Mon
Jan 28- Wed / Mar 25- Wed / May 27- Wed / July 22- Wed / Sept 23- Wed / Nov 20- Fri
Feb 16- Mon / Apr 17- Fri / June 15- Mon / Aug 17- Mon / Oct 16- Fri / Dec 7- Mon
Feb 20- Fri / Apr 20- Mon / June 24- Wed / Aug 21- Fri / Oct 19- Mon / Dec 9- Wed
Feb 25- Wed / Apr 22- Wed / June 26- Fri / Aug 26- Wed / Oct 28- Wed / Dec 18- Fri
NEW DATES: (* attach your current CPR card)
Jan 5 (Mon) & Jan 12 (Mon) / Apr 16 (Th) & Apr 18 (Sat) / Aug 7 (Fri) & Aug 8 (Sat) / Nov 19 (Th) & Nov 21 (Sat)
Jan 15 (Th) & Jan 17 (Sat) / May 11 (Mon) & May 13 (Wed) / Aug 12 (Wed) & Aug 19 (Wed) / Dec 3 (Th) & Dec 5 (Sat)
Feb 2 (Mon) & Feb 4 (Wed) / May 20 (Fri) & May 22 (Sat) / Sep 9 (Wed) & Sep 16 (Wed) / Dec 14 (Mon) & Dec 16 (Wed)
Feb 11 (Wed) & Feb 18(Wed) / June 4 (Th) & June 6 (Sat) / Sep 25 (Fri) & Sep 26 (Sat)
Mar 2 (Mon) Mar 9 (Mon) / June 8 (Mon) & June 10 (Wed) / Oct 5 (Mon) & Oct 7 (Wed)
Mar 27 (Fri) & Mar 28 (Sat) / July 16 (Th) & July 18 (Sat) / Oct 15 (Th) & Oct 17 (Sat)
Apr 6 (Mon) & Apr 13 (Mon) / July 20 (Mon) & July 27 (Mon) / Nov 2 (Mon) & Nov 9 (Mon)
1st Choice: / 2nd Choice:

Nurse Manager or Director information

*Nurse Manager’s Email
*Nurse Manager’s Phone / *Nurse Manager’s Fax
*Nurse Manager’s or
Director’s Signature

* Required

Please fax or mail your request to: (Confirmation will be faxed or emailed to you within 48 hours - if you don’t receive a confirmation please call our office)

Health Educators, Inc., 8010 Staples Mill Rd., Richmond, VA 23228

Phone: (804) 553-0460; Fax: (804) 553-0463

Email: Website: www.healtheducatorsinc.com