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Registration Form

Click here to download our 2011 registration form.

* Denotes a mandatory field

General
Title   
Name*   (Name, Initials)
Surname*  
Calling Name    (for name tag)
Email Address*  
ID/Passport Number   
Mobile Telephone   
Home Telephone   
Work Telephone   
Address details
Home Address    (e.g. Home/Office)
Address   
Address   
Suburb   
City   
Code   
Country   
Work Address    (e.g. Home/Office)
Address   
Address   
Suburb   
City   
Code   
Country   
Postal Address    (e.g. Home/Office)
Address   
Address   
Suburb   
City   
Code   
Country   
Academic history
  Qualifications Institution Date
  
  
  
  HPCSA Registration number    
Summarized C.V.
  Present position held   
  Previous position held   
  Other courses attended   
Basic life support certificate
  Please fax us a copy of valid certificate if applicable to +27 (0)11 678 5087
  AHA Basic Life Support Healthcare Provider Certificate No    
Dated   
    Issued by   
Course booking
  Please select date of course.
     5 hour Basic Life Support for Healthcare Providers Course
     2-Day Paediatric Advanced Life Support (PALS) Provider Course
     2.5-Day Advanced Cardiovascular Life Support (ACLS) Provider Course
     2-Day Advanced Cardiovascular Life Support for Experienced Providers
         Course
     2-Day Advanced Medical Life Support (AMLS) Course for Doctors
     1-Day Emergency ECG and Pharmacology Course
     1-Day Advanced Neonatal Life Support (NRP) Course
Undertaking
I enclose a cheque/postal order/credit card number payable to ACADEMY OF ADVANCED LIFE SUPPORT. (Textbooks will be forwarded on receipt of payment). I understand that I will be required to pass the entry examination in order to successfully complete the Course. (It is recommended that the Texbook be obtained at least 2 months prior to Course participation to allow sufficient time for self-study)
Tick appropriate blocks (All prices include VAT):
       R 850.00      5 hour Basic Life Support for Healthcare Providers Course
       R 2500.00      2-Day Paediatric Advanced Life Support (PALS) Provider Course
       R 2500.00      2-Day Advanced Cardiovascular Life Support (ACLS) Provider Course
       R 2600.00      2.5-Day Advanced Cardiovascular Life Support for Experienced Providers Course
       R 2600.00      2-Day Advanced Medical Life Support (AMLS) Course for Doctors
       R 1200.00      1-Day Emergency ECG and Pharmacology Course
       R 1500.00      1-Day Advanced Neonatal Life Support (NRP) Course
Payment details
Credit card number        Expiry date   
Card type                  CVV      (Last 3 numbers on the back)
Terms and conditions
PAYMENT BY DIRECT DEPOSIT:
STANDARD BANK, NORTHCLIFF. BRANCH CODE: 006305. ACCOUNT NUMBER: 201 675 781.
ACCOUNT NAME: ACADEMY OF ADVANCED LIFE SUPPORT.

TERMS AND CONDITIONS
Cancellation more than 1 month prior to Course - 75% REFUND
Postponement more than 3 weeks prior to Course - R350,00
Cancellation less than 1 month prior to Course - NO REFUND
Postponement less than 3 weeks prior to Course - R1 000,00
Failure to attend Course - NO REFUND
Only one postponement will be allowed

By submitting this form I confirm acceptance of the terms and conditions of participation and postponement conditions.
 
*Please answer the following question   1 + 8 =        
 
     
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