Fillable anced Life Support Course Roster Pediatric Adv (Augusta Technical College)

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anced Life Support Course Roster Pediatric Adv (Augusta Technical College)

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Pediatric Adv
anced Life Support Course Roster
Emergency Cardiovascular Care Programs
Course Information
PALS Course
PALS Update Course
HeartCode
®
PALS
PALS Instructor
Lead Instructor __________________________________________
Lead Instructor ID#
Card Expiration Date
Training Center
Training Center ID#
Training Site Name (if applicable)
Address
City, State ZIP
Course Location
Course Start Date/Time
No. of Cards Issued
Course End Date/Time
Student-Manikin Ratio
Total Hours of Instruction
Issue Date of Cards
Assisting Instructor (Attach copy of instructor aligned with a TC other than the primary TC)
Name and Instructor ID# Card Exp. Date
Name and Instructor ID# Card Exp. Date
1. 5.
2. 6.
3. 7.
4. 8.
I verify that this information is accurate and truthful and that it may be conrmed. This course was taught in accordance with AHA guidelines.
Signature of Lead Instructor Date
KJ1216 PALS 8/17 © 201
7 American Heart Association
KJ1216 PA
LS 8/17 © 2017 American Heart Association
Name and Email
Please PRINT as you wish your name to appear on your card. Please print
email address legibly.
Mailing Address/Telephone
Complete/
Incomplete
Remediation/Date
Completed
(if applicable)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Course Participants
Date Course Lead Instructor Lead Instr. ID#
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anced Life Support Course Roster Pediatric Adv (Augusta Technical College)

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Completed 29 January 2021

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