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 aha@laniertech.edu.
Course Location:
Course Coordinator's Name:
Coordinator's Address:
City, State, and Zip Code:
Coordinator's E-mail Address:
List Assisting Instructors / Specialty Faculty and their Affiliated Training Center (TC)
Physician's Name:
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:
Total #
of Cards
Needed
01:
02:
03:
04:
TC: 06: TC:
05:
07:
08:
09:
10:
TC:
TC:
TC:
TC:
TC:
TC:
TC:
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:
Check #
Include PO# if requesting invoice.
If paying by Credit Card you will be called
when cards are ready.
Cash
Coordinator's Phone Numbers:
Course Type
Initial
Recertification
Received
Entered
Paid/Inv
Mailed
Print Form
Course Participant Complete? First Time Student Score
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