Physician, Dentist, Fellow, Resident, rn, Paramedic, Med. Student, Other

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Email Address:  

Telephone

 (Work)

:

Telephone 

(Home or Cell)

: 

(Physician, Dentist, Fellow, Resident, RN, Paramedic, Med. Student, Other (please specify)

Professional Status:

Specialty: 

ATLS REGISTRATION FORM

(Advanced Trauma Life Support)

First Name:                                                      Last Name:                                                 

Mailing Address 

(including Postal Code)

: 

PLEASE Write in Course Date Requested:

* This is a definite registration for the above course.  Your payment is due one month prior to the course date, or as soon as possible.

CANCELLATION POLICY

email:[e-mail]   Telephone: [phone] or FAX: [phone] 

* Please return this Registration Form to our office by email, fax or regular mail.

ACLS Program Office, Room H-265

2075 Bayview Avenue

Toronto, ON 

M4N 3M5

If you have further questions, please contact Terry G. Smith, Program Manager, at the ACLS Office by

    3. If you cancel your booking 2 weeks or more in advance of the course date, you will receive a full refund, minus the Administration Fee

    2. If re-scheduling less than two weeks prior to your course, there is a $50 Re-scheduling Fee

    4. If you cancel your booking 1-2 weeks or more in advance of the course date, you will receive a refund of half the fees paid

* The ATLS Provider Manual will be mailed via First Class Mail when the Registration Form and payment have been received at the ACLS Office.

*  If your payment is by cheque (in Canadian funds), please make it out to "Sunnybrook Hospital" and mail it to our office at:

Sunnybrook Health Sciences Centre

    1. All cancellations are subject to a $50.00 Administration Fee

Amount being charged: $

Please be assured that your credit card information will be used in strict confidence

    5. If you cancel your booking less than one week (7 days) in advance of the course date, NO refund can be given

    7. Course dates are subject to change or cancellation

  Sunnybrook Health Sciences Centre is Fully Affilicated with the 

Billing Address (if different from above):

PAYMENT BY  CREDIT CARD

*** If paying fees by CREDIT CARD, please include the following information:

Cardholder Name (as printed on card):

Provider Manual Needed? (YES / NO):

Credit Card Type (Visa/ MasterCard/ Discover):

Expiry Date (mm/yy):

    6. If you re-schedule your booking less than one week (7 days) in advance of the course date, you will need to pay the fees again

CCV Code (3 digit Verification Code on back of card):

Credit Card Number: