Vail Valley Medical Center Registration Form 2017

TNCC

2017 TNCC COURSE DATES:
June 29th & 30th
Mandatory Course Definition: Your hospital pays for the course and your time to take the course.
You must get your director to sign the registration form for all courses. Please remember that if it is not a required certification for your job description it will not be paid for unless you either pay it on your own or apply for the WSSG scholarship. Please ask your director about this process.
I am a VVMC employee (Supervisors Name: )
I am a SASMC employee (Supervisors Name: )
I am a Centura employee (Facility, Cost Center#, and Supervisors Name: )
(Non-SASMC employees) we cannot process registrations without knowing your facility name and cost center number
I am a VVH employee (Supervisors Name: or Nancy Smith’s Signature)
Supervisor Signature: ______Date: ______
Name:
Email:
Phone:

Vail Valley Medical Center Registration Form 2017

181 W Meadow Drive Vail, CO

Level 0 in the A&B Conference Rooms

7:30am -5pm

NOTE TO ALL PARTICIPANTS: Preparation: Trauma Nurse Core Curriculum (TNCC) is a rigorous 2 day course which requires strong preparation prior to the course for the participant to have a positive experience in class. Obtaining and reviewing the 7th Edition manual prior to class is a must. Byregistering for this course, you acknowledge that every effort will be made to obtain and review the 7th EditionTNCC manual prior to class.This course is pass/fail, so adequate preparation is essential. Please indicate your work location and book choice below.

I am Vail Valley Medical Center employee: Please check one:

I wish to purchase the 7th Edition TNCC manual. Charge $75 to the credit card below

I will pick up a 7th Edition TNCC manual from my facility or acquire it on my own.

I am a SASMC Employee: Please check one:

I wish to purchase the 7th Edition TNCCmanual. Charge $75 to the credit card below

I will pick up a 7th Edition TNCC manual from my facility or acquire it on my own.

I am a Centura employee, but not a SAMSC employee: Please check one

I wish to purchase the 7th Edition TNCC manual. Charge $75 to the credit card below.

I will pick up a 7th Edition TNCC manual from my facility or acquire it on my own.

I am a Valley View Hospital Employee: Please check one

I wish to purchase the 7th Edition TNCC manual. Charge $75 to the credit card below.

I will pick up a 7th Edition TNCC manual from my facility or acquire it on my own.

If applicable, mail the manual to:

Name:

Address:

City: State: Zip:

Credit card information MUST be given to process your registration: This card will NOT be charged unless you wish to purchase a manual, are ano showfor the class, orfail the class. The HEN will bill ALL participant hospitals directly once you have completed and passed the course. Excusable absences: Emergency staffing need confirmed with manager, inclement weather, and illness with a Doctors excuse.

Credit Card #: Type: MC VISA DISC

Exp date (mm/yyyy):

Name as it appears on the card:

Electronic Signature (type name here):

Please Note: You can change classes or drop the class up until the time the class is “closed”. This will occur 14 days (10 business days) prior to the class start date. If you have unusual circumstances that arise and need to discuss it, just give us a call.

If you are a no showfor the course, or fail the course, the course fee ($375) or ($435) if you purchased a manual from us) will be charged to your credit card. Excusable absences: Inclement weather; Emergency staffing- manger verification; Illness with written MD excuse.

Once this registration is received in our offices, you will receive a confirmation email with more information about the class. Please contact Katie with any questions or concerns.

Please return by Fax or Email to:

Katie Stillman Client Services Coordinator / Fax: (303) 312-1168 / Phone (303)380-0343 /