CLASS REQUEST INFORMATION SHEET

PRIVATE CLASS REQUEST FORM

Welcome!

For classes, please schedule 2 or more weeks in advance to allow scheduling.
Name of Agency/Office*
Name of Person Completing Form*
Requested Class Date*

MonthDayYear
Date
Class Date 2 (If 2 day class)

MonthDayYear
Date
Class Time*
Alternate Class Date #1

MonthDayYear
Date
Alternate Class Date #2

MonthDayYear
Date
If scheduling multiple classes (ie - for the year) please list the class dates below
Class Type*

ACLS Renewal (must have current cert)ACLS Provider Course (new or expired certs - 2 days)PALS Renewal (Pediatric - must have current cert)PALS Provider Course (new or expired certs - 2 days)BLS Provider - Students may be new, current, or expired. Class is approximately 3.5 hours long.BLS Renewal - All participants MUST have proof of a current BLS card. Class is approximately 2 hours long. NOTE: If new or expired, add information in Other Information at the end of formBLS Skills - Hybrid learning course. Students are required to complete AHA BLS Heartcode online prior to class, and the hands-on portion is approximately 1.5 hours long. Online time will vary per individual.ENPC (2 days) (Emergency Nurse Pediatric Course - nurses only)TNCC (2 days) (Trauma Nurse Core Course - nurses only)Site MegacodesEKGEKG-12 leadHeartsaver CPR/AED (non-medical providers)Heartsaver First Aid (non-medical providers)Heartsaver Pediatric First Aid (non-medical providers)Friends & Family CPR (no certs)QMAPOther
AHA Class Type*

BLS (Basic Life Support)ACLS (Advanced Cardiac Life Support)PALS (Pediatric Advanced Life Support)PEARS (Pediatric Emergency Assessment, Recognition & Stabilitzation)Heartsaver (non-medical providers - CPR and/or First Aid - with certification)Family & Friends CPR\AED (no certification)Non-AHA Class (please choose other class type below)
Heartsaver Class Types*

CPR/AED AdultCPR/AED Adult/ChildCPR/AED Adult/Child/InfantFirst Aid onlyFirst Aid/ CPR/AED - AdultFirst Aid/CPR/AED - Adult /ChildFirst Aid/CPR/AED - Adult/Child/InfantPediatric First Aid/CPR/AED - Child/InfantPediatric First Aid with Adult/Child/Infant CPR AEDUnknown
BLS Class Type*

BLS Provider - Students may be new, current, or expired. Class is approximately 3.5 hours long.BLS Skills - Hybrid learning course. Students are required to complete AHA BLS Heartcode online prior to class, and the hands-on portion is approximately 1.5 hours long. Online time will vary per individual.BLS Renewal - All participants must show proof of a current BLS card. Class is approximately 2 hours long.Unknown
ACLS/PALS class type*

Provider - (new or expired certs - 2 days)Provider - (2 days in 1) New or expired certs. Extended day. (Not recommended for Providers new to the field)Renewal - requires current certificationHeartcode (skills class) - Students take AHA Heartcode course online prior to skills session. For current, new or expired certs. Approx. 1 1/2 hrs plus individual time for online.
Will BLS be completed during this class?*

YesNoI would like more information
Notes regarding class type request
ENA Class Type

TNCCENPC
Other Classes

NRP (Neonatal Resuscitation Program)ECG/EKGQMAPSite MegacodesStop the BleedOther
Number of students in class*
We do require a minimum payment for 5 students for BLS or Heartsaver classes, 4 students for ACLS and PALS, and 8 students for QMAP and ECG. Please note that, per AHA guidelines, ACLS and PALS requires a minimum of 3 participants for the skills/megacode testing in order to accommodate the team approach. We are able to utilize non-certifying staff from your facility to participate in the megacode portion of the class.
Please be as accurate as possible in order to allow us to schedule instructors properly. You may give a small range with a minimum and a maximum. AHA - PALS and ACLS classroom courses have an instructor:student ratio of 1:8 ; BLS & Heartsaver classroom courses are 1:9 and all skills checkoffs are 1:6. All ENA (ENPC & TNCC) classes have a ratio of 1:6.
Will you need new course books? Please note: AHA books are required and must be the current 2020 guidelines edition BLS, ACLS, and PALS. Other book current editions are - TNCC 9th edition, ENPC 6th edition and NRP 8th edition

YesNo - class participants have access to the current bookPlease send more info
EdCor is no longer shipping AHA books, but we can send you a link in our confirmation that will allow you to order books directly from the vendor with no charge for shipping if the total is over $100. You will also have the option to pick up the books at our office or have them brought to the class (books may be needed for Pre-study).
If books are needed - how many? Each individual is required to have their own book in class. Books are not required for AHA Skills classes.
Names and Email Addresses of Class Participants (if known)
This will allow us to register them in the class and send preparation/study and a reminder email to the participants.
Names and Email Addresses of Class Participants (if known)
This will allow us to register them in the class and send preparation/study material and a reminder email to the participants
Does your site have an AED?

YesNo
If so, what is the brand of AED?
Audio Visual Equipment at your site:

TelevisionDVD/BluRay PlayerComputerProjectorScreen/Blank wall for projectionNone- Please have instructor bring to classOther
Other
Registration
Registration options

Please post on the EdCor website and students will self registerIf the class is below the minimum number of students, the class may be opened to outside students (same professional area)Your site will notify employees of the class (students will complete an information form for EdCor @ the class). Please send us names and email addresses of class attendees.
Class attendees w/ emails (for option #3). This information is necessary for the class roster and ecard certificates. It also allows us to send class preparation instructions and a class reminder.
Payment options*

Please have students pay deposit (which will be held if they do not show)We are guaranteeing payment for the quoted minimum number of students - no deposit for studentsStudents will pay individually
Contact Information
POINT PERSON*
TITLE & DEPARTMENT
EMAIL
example@example.com
PHONE NUMBER*
PREFERRED CONTACT METHOD

PhoneEmailOther
ID #s for electronic cards should be sent to:*
(for employers to access cards - please type email if different from class contact)
Class site Address
STREET ADDRESS*
Building/Suite #
Type of room*

ClassroomConference RoomWaiting RoomOther
CITY*
STATE
ZIP*
Billing Information
ACCOUNTING POINT PERSON*
EMAIL*
example@example.com
PHONE NUMBER
COID #/ COST CENTER INFORMATION (If applicable)
How did you hear about us?

previous classweb searchyellow pages/Dexconferenceformer studenthospitalFacebookOther
Other comments/information
Please note that submitting this form does not guarantee the class date (unless you have already confirmed this date with EdCor). You will receive an email from Edcor with final confirmation.
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