Course Bookings

UNDERTAKING

Enclose an EFT proof of payment made to ACADEMY OF ADVANCE 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 Textbook be obtained at least 6 weeks prior to Course participation to allow sufficient time for self-study)



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- Available
 
- Booked
 
- Pending
 
- Partially booked

Personal Information:

Email*

Title*

First Name*

Middle Initial

Surname*

Identity (ID) Number*

Calling Name (For name tag)*

Home Tel (e.g. +27 82 555 0000)

Cellphone Number (e.g. +27 82 555 0000)*

Work Tel (e.g. +27 82 555 0000)

Fax Number (e.g. +27 82 555 0000)

HPCSA Registration Number

Dietary Requirements:

Physical Home Address*

Home Postal Code*

Physical Work Address*

Work Postal Code*

Courier Options:

 

 

 

 

Other Courier Address (Physical address only)

Other Courier Postal Code

 

Qualification (1)

Qualification Institution (1)

Qualification Date (1)

Qualification (2)

Qualification Institution (2)

Qualification Date (2)

Qualification (3)

Qualification Institution (3)

Qualification Date (3)

 

Summarized C.V. (Last 3 years):

Current Employment Position

Previous Employment Positions (3 years)

Other Courses Attended

 

BLS Certificate (Copy of certificate will be required):

AHA BLS Provider Certificate No

AHA BLS Provider Certificate Dated

AHA BLS Provider Certificate Issued By

I heard of this course through (Please tick relevant option):

 

 

 

 

 

 

 

Other, please specify:

 

TERMS AND CONDITIONS:

Cancellation more than 1 month prior to Course - 75% REFUND

Cancellation less than 1 month prior to Course - NO REFUND

Failure to attend Course – NO REFUND

Only one postponement at a fee of R1,500.00 will be allowed

Reprinting of certificates at a fee of R350.00

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