Seating is Limited. Register Today! You are enrolling in: Registration Fee:  atls® Provider Course $750

Seating is Limited. Register Today!

You are enrolling in: Registration Fee:

 ATLS® Provider Course $750

o ATLS® Provider Course* $650

o ATLS® Provider Course (Auditor) $250

o ATLS® Refresher Course** $450

o ATLS® Instructor Course*** $700

*This amount applies to only students who are completing their Residency or Fellowship, or who are an APN, PA or Med Student. All other students attending the Student course will enroll at the tuition rate of $750.

**All applicants registering for re-verification must include a copy of their current ATLS® card when submitting their registration.

***Instructor Candidates must submit a letter of approval from their State Chairman before attending an out of state course. Please contact the Course Coordinator for more information.
Course Date:_______________________________Total:____________________

Last Name: ________________________________________________________

First Name: ________________________________________________________

Degree:____________________________________________________________

Specialty:___________________________________________________________

Street Address:_______________________________________________________

City_____________________________State_________ZIP___________________

E-mail Address:_______________________________________________________

Phone:______________________________________________________________
Special dietary needs or requests:________________________________________

Payment

o Check o Visa o Mastercard Discover American Express

Card number__________________________________________

Expiration Date________________________________________

Security Code ________________________________________

Name on Card ________________________________________

Please mail checks payable to: St. Mary’s Trauma Center, Attn: Mary Raley, 3700 Washington Ave, Evansville, IN 47750