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American
Heart
Association®
GVVINNETT
Continuing
Education
_______________________________________________
E-CARDS
American Heart Associaon Emergency Cardiovascular Care Program Course Roster
**Note: Please ll out roster completely to avoid any delay in processing the informaon.**
BLS Healthcare Provider E-Card Inial Renewal
ACLS Provider E-Card Inial Renewal
PALS Provider E-Card Inial Renewal
HS First Aid CPR AED E-Card Inial Renewal
HS CPR AED E-Card Inial Renewal
HS First Aid E-Card Inial Renewal
HS Pediatric First Aid CPR AED E-Card Inial Renewal
K-12 HS First Aid CPR AED E-Card Inial Renewal
Assisng Instructors/Specialty Faculty:
Instructors Name: _____________________________________________________
Phone Number: _______________________________________________________
Course Locaon*: _______________________________________________
*Locaon will be printed on card
Course Start Date/Time: ________________________________________________
Course End Date/Time: _________________________________________________
Total Hours of Instrucon: _____________________________
Training Center Name: Gwinne Technical College CTC
5150 Sugarloaf Parkway Lawrenceville, GA 30043
678-226-6254
1. 4.
2. 5.
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I verify that this informaon is accurate, truthful and that it may be conrmed. This course was taught in accordance with AHA guidelines.
Signature of Course Director/Lead Instructor: ________________________________________________________________ Date: ________/________/____________
SUBMIT VIA: E-mail CommunityTraining@GwinneTech.edu
Oce Use Only: Date Rcvd: __________ Amount Rcvd: __________ Payment Type: Online Payments only
12/12/2019
V
~
American
Heart
Association®
GVVINNETT
Continuing
Education
PLEASE PRINT CLEARLY
E-CARDS
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Date _______________ Course __________________________ Instructor _____________________________________________
Please PRINT your name as you wish
it to appear on your card
E-mail Phone
Examinaon
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Remediaon Provided/
Date Completed
Course
Completed
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Issued
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Y N
3.
Y N
4.
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5.
Y N
6.
Y N
7.
Y N
8.
Y N
9.
Y N
10.
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