Fillable Educational Activity Registration Form

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Educational Activity Registration Form

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Mail Code: 3115 | Email: ptc.registration@ksau-hs.edu.sa | Tel. No.: +966 11 429 9999 Ext. 91111 | Fax Ext. No.: 91132
Please print clearly. Your name will appear on your "Activity Certificate" exactly as spelled on this form.
First:
Middle:
Last:
Professional Title: SCFHS ID No.:
Ministry of NG-HA Badge No.:
Nationality:
Hospital / Institution:
Department: Mail Code: P.O. Box No.:
City: Postal Code: Country:
CONTACT DETAILS:
(Include telephone area codes if applicable)
Telephone No.: Pager No.: Fax No.:
Mobile No.: E-mail Address:
Activity Code:
Activity Title:
Date:
Gender:
For all LIFE SUPPORT COURSES:
Provider
Recertification
Activity Date:
[Please mark (M) where applicable]
Male
Female
Recommended renewal date:
Valid
Expired
Activity Registration Form
ACTIVITY REQUESTED:
Cash
Amount in SAR:
OR No.:
Date:
Bank
Amount in SAR:
OR No.:
Date:
PTC Bank Account Details:
Bank Name: ARAB NATIONAL BANK
Account Name: ESC-EMPLOYEE SOCIAL CLUB
Account No.: 0108 0052 0891 0460
IBAN No.: SA9330400108005208910460
Notes:
* WRITE the correct PTC Bank Account information to
ensure payment is forwarded to the PTC Account.
* E-MAIL a copy of the validated deposit slip
with your registration form to PTC.
* CALL or E-MAIL the PTC Registration Office to confirm
acceptance of your registration and payment.
MODE OF PAYMENT:
PERSONAL INFORMATION:
Remarks:
How did you know about PTC?
"TRANSFER OF ACTIVITY FEE TO OTHER ACTIVITY IS NOT ALLOWED. ORIGINAL RECEIPT MUST BE ATTACHED IN CASE OF REFUND."
Notes:
* Applicable fee depends on the validity of
current certification
* Please present a copy of course ID card or
certificate for verification.
REGISTRATION POLICY:
1. Waiver of registration fee is acceptable only if subject participant is sponsored and officially approved by the PTC
Management.
2. Registrant should receive an official receipt after payment of the registration fee and no further actions shall be
taken without presenting the original receipt.
3. All registrations are completed via mails, e-mails and in person will be confirmed upon receiving the registration
fee.
4. Prefer to register for the life support courses/mandatory courses before the expiration date as appears on the
course certificate/card otherwise, he/she will pay the full amount of the course.
5. In the event that the new guidelines and manuals are already available, the PTC reserves the right to charge
"provider’’ fee including the amount of the new manual".
6. No registration shall be made without payment unless the Educational Activity is announced as, free registration.
7. Registration is valid only if completed and submitted the registration form.
8. The registrant is responsible to read and sign for having read and the policies stated herein, which is located at the
bottom part of this page.
CANCELLATION, TRANSFER AND REFUND POLICY:
In case participant would like to reschedule or transfer to another course
1. Inform the PTC at least four (4) weeks prior to the scheduled course commencement date. If participant failed to
do so, the course payment will be forfeited without any question in case of complete cancellation. In case of
reschedule charges will be applied: SAR 50.00 for Basic Courses and SAR 100.00 Advance courses.
2. In case of illness or emergency cases, registrant needs to provide proper documentation.
3. Reschedule of confirmed registration due to work responsibilities and shortage of staff shall require submission to
the PTC - a letter from the registrant's direct supervisor requesting for re-booking or rescheduling to the next
available activity. Refund is not applicable on this case.
4. Return of used manual is not refundable, including its shipping charges.
5. "No show," on the day of the activity shall indicate, "No refund,"
If a participant decides to withdraw from a course after their registration is conformed, the following applies:
1. An administration charge of SAR 50.00 or 20% of the total course fee (whichever is greater) will be charged in the
period of up to four (4) weeks prior to the scheduled course date.
2. Forfeiture of the full course fees is applied if the applicant decided to withdraw less than four (4) weeks prior to
the course commencement date.
3. Any cancellation made by the registrant in less than the late registration date of the activity, as advertised or
announced, the activity fee shall be forfeited.
4. In exceptional circumstances, as deemed by the TCC, participants will receive a full or partial refund of the course
fee.
Important general implementation:
1. Smoking is prohibited in and during all programs.
2. The American Heart Association AHA disclaimer is implemented for any courses that students are charged.
3. Participant’s phones and pagers must be switched off during Emergence Care Courses .
4. Participants are required to bring the manual/book, otherwise they will not be accepted to attend the course and
rescheduling with new payment.
5. Reproductions of AHA materials are not allowed.
6. No titles implemented for certificates issuing.
7. Late comers without notice more than 15 minutes will not be accepted to attend the course and they will be
considered absent.
8. Pregnant and illness participant's is responsible to inform the PTC about her situation in advance.
9. Participants must not leave anything behind them in the classroom (booklets, files,..etc.)
DISCLAIMER POLICY
While the Postgraduate Training Center makes every effort to conduct the activities as advertised, we reserve the right to change the
schedule and/or the instructors without prior notice, and to cancel any activities without liability. In the latter case, there is a full
refund of activity fee to participants.
I have read and agree to the above stated terms and conditions regarding PTC Registration, Cancellation, Transfer and Refund
Policy.
Registrant Signature:
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Educational Activity Registration Form

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Completed 21 September 2021

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