Select The Course Taught:
AHA Training Center
2535 Lanier Tech Drive, Deal Hall Phone: 770.533.6993
Gainesville, GA 30507
ECC Programs Course Roster
ALL ROSTERS MUST BE TYPED FOR ACCURACY. Incomplete rosters will extend processing time. Email roster to firstname.lastname@example.org.
Course Coordinator's Name:
City, State, and Zip Code:
Coordinator's E-mail Address:
List Assisting Instructors / Specialty Faculty and their Affiliated Training Center (TC)
ACLS/PALS Physician Available
Manikins Cleaned By:
Course Start Date:
Course Start Time: Course End Time:
Course End Date:
Total Hours of Instruction:
Student to Manikin Ratio:
TC: 06: TC:
I verify this information is correct and it may be confirmed. I further attest that this course was conducted according to AHA standards.
Date: # of Participants: Signature of Course Coordinator:
Include PO# if requesting invoice.
If paying by Credit Card you will be called
when cards are ready.
Coordinator's Phone Numbers: