Pediatric Advanced Life Support (PALS) INSTRUCTOR COURSE

The American Heart Association (AHA) strongly promotes lnow;edge and proficieny in BLS, ACLS and PALS courses and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent sponsorship by AHA. Any fees charged for such a course, except for a portion of fees needed for AHA course materials, does not represent income to the Association.
Pediatric Advanced Life Support (PALS) INSTRUCTOR COURSE

2022 Registration Form
Date

Month Day Year
Date
Name

First Name Last Name
Employee ID (if COA employee)
Educator (or Supervisor)
Work Phone

Area Code Phone Number
Email:
firstname.lastname@childrensal.org (if employee)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Non COA List place of employment
Profession (Job Title):

MD Resident/Intern Dentist Pharm/Pharm D Resp. Therapist CRNP RN LPN
Select ONE PALS 2022 Instructor Class Below:

January 25th June 28th September 20st
**NOTE***You must have received "Instructor Potential" status from the PALS course taken within the past 12 months to attend.
PAYMENT METHOD BELOW: Select if you are a UAB or NON-Children's Employee

I am responsible for the course fee of $150.00. I understand that payment by check payable to Nursing Education must be received before access is given to online modules. NOTE: Payments are non-refundable.
Shaundra Blakemore, MD: Medical Director ; Elsie Anwah, RN: Course Director
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