Clinical Training Center Registration Form

Clinical Training Center Registration Form

BLS, ACLS and PALS Certification Classes
Name*

First NameLast Name
Email*
example@BMC.org
If you are faculty, Staff, Resident, or an Employee of Boston Medical Center, St. Elizabeth's Medical Center, Good Samaritan Medical Center, or BMC Brockton Behavioral Health Center- select BMC Employee below
I am:*

BMC EmployeeEmployee of a BMC affiliated Community Health Center (Codman, Dothouse, NeighborHealth, etc...)Faculty, Staff, Student or Employee of BU School of Dental MedicineBMC Travel or Dialysis Nurse, BUAP Employee, BUSM Student or Graduating BMC ResidentMedical Professional from another facility
Note: If you are from nursing- your online BLS Assignment will come from the Nursing Education Department.

BMC Health System Faculty and Staff
At which campus do you work:
Position at BMC Health System: *
i.e. MD, DO, Resident, Fellow, CRNA, RN, C.N.A., Tech, Resp Therapist, etc...
BMC Health System ID Number *
i.e. 10011111
What department, or floor are you assigned to *
i.e. Emergency Medicine, GIM, Cath Lab, Neuro, M7W, SICU, etc...
What class or classes do you wish to register for? (Select all that apply)*

* Basic Life Support (BLS)* Advanced Cardiovascular Life Support- Initial Certification* Advanced Cardiovascular Life Support - Recertification* Pediatric Advanced Life Support- Initial Certification* Pediatric Advanced Life Support- Recertification

Employee of BMC Affiliated Community Health Center
Name of Community Health Center?*
i.e. Codman Square, East Boston, South Boston, etc...
Level of Certification?*
i.e. MD, RN, Technician, etc...

BU School of Medicine Employee, BUSM Student, BUSM Graduate or Graduating BMC Resident or Fellow
BMC or BU ID number?*
What is your current status?*

Faculty or staff of the BU School of Dental MedicineBUSM Student/GraduateGraduating BMC Resident/FellowBMC Travel or Dialysis NurseEmployee of BUAP ( Copley Square Medical Practice)

Medical Professional from another facility
Position or certification level (i.e. MD, RN, Paramedic, Mental Health Worker...)*
Name of Facility:

My Classes*

Basic Life Support Certification (BLS)HeartCode BLS with in-person skills session. (Can be taken alone or added to ACLS or PALS)

$85.00

Advanced Cardiovascular Life Support Certification (ACLS)HeartCode ACLS with in-person skills session

$295.00

Pediatric Advanced Life Support Certification (PALS)HeartCode PALS certification with in-person skills session

$295.00

Total

$0.00

BMC Health System Faculty and Staff