WHO/ICRC/IFEM Basic Emergency Care course registration form

WHO/ICRC/IFEM Basic Emergency Care course registration form
This WHO/ICRC/IFEM Basic Emergency Care (BEC) course registration form is to be completed by the BEC course sponsoring organisation. This form is to be read with the IFEM BEC credentialling guidance. For further information contact ACEM Global Emergency Care Desk on gecnetwork@acem.org.au.
1. Details of the sponsoring organisation responsible for delivering the BEC course/s
Name of sponsoring organisation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name/s of other relevant stakeholders and their role in delivery of the BEC course/s
Name of the nominated representative of the sponsoring organisation*

First NameLast Name
Email of the nominated representative of the sponsoring organisation *
example@example.com
Phone number of the nominated representative of the sponsoring organisation *
Please enter a valid phone number.

2. Details of proposed BEC course/s
Please complete the following set of questions for each BEC course that you plan to register in this form. Up to four different BEC courses can be registered using this form.
BEC Course 1
Type of BEC course*
Proposed date of BEC course*

DayMonthYear
Date
Location of BEC course*
Number of participants expected*
Anticipated mix of participant genders and cadres (eg. nurse, doctor, etc)*
Names and credentials of the proposed trainers/facilitators for BEC course*
The name and credentials of the proposed BEC course director/s*
Details of the proposed course/s arrangements, demonstrating sufficient funding for the delivery of the course/s, equipment and printing capacity and infrastructure at the venue location*
Provision of Letter/s of Support: If the sponsorship organisation is not registered in the country in which they are delivering a course they must submit a letter of support from a relevant local or regional institution, unless they are conducting a course that only includes their own staff (as per IFEM guidelines).

Cancelof
BEC Course 2
Type of BEC course
Proposed date of BEC course

DayMonthYear
Date
Location of BEC course
Number of participants expected
Anticipated mix of participant genders and cadres (eg. nurse, doctor, etc)
Names and credentials of the proposed trainers/facilitators for BEC course
The name and credentials of the proposed BEC course director/s
Details of the proposed course/s arrangements, demonstrating sufficient funding for the delivery of the course/s, equipment and printing capacity and infrastructure at the venue location
Provision of Letter/s of Support: If the sponsorship organisation is not registered in the country in which they are delivering a course they must submit a letter of support from a relevant local or regional institution, unless they are conducting a course that only includes their own staff (as per IFEM guidelines).

Cancelof
BEC Course 3
Type of BEC course
Proposed date of BEC course

DayMonthYear
Date
Location of BEC course
Number of participants expected
Anticipated mix of participant genders and cadres (eg. nurse, doctor, etc)
Names and credentials of the proposed trainers/facilitators for BEC course
The name and credentials of the proposed BEC course director/s
Details of the proposed course/s arrangements, demonstrating sufficient funding for the delivery of the course/s, equipment and printing capacity and infrastructure at the venue location
Provision of Letter/s of Support: If the sponsorship organisation is not registered in the country in which they are delivering a course they must submit a letter of support from a relevant local or regional institution, unless they are conducting a course that only includes their own staff (as per IFEM guidelines).

Cancelof
BEC Course 4
Type of BEC course
Proposed date of BEC course

DayMonthYear
Date
Location of BEC course
Number of participants expected
Anticipated mix of participant genders and cadres (eg. nurse, doctor, etc)
Names and credentials of the proposed trainers/facilitators for BEC course
The name and credentials of the proposed BEC course director/s
Details of the proposed course/s arrangements, demonstrating sufficient funding for the delivery of the course/s, equipment and printing capacity and infrastructure at the venue location
Provision of Letter/s of Support: If the sponsorship organisation is not registered in the country in which they are delivering a course they must submit a letter of support from a relevant local or regional institution, unless they are conducting a course that only includes their own staff (as per IFEM guidelines).

Cancelof
Should be Empty:

WHO/ICRC/IFEM Basic Emergency Care course registration form

1. Details of the sponsoring organisation responsible for delivering the BEC course/s

2. Details of proposed BEC course/s

BEC Course 1

BEC Course 2

BEC Course 3

BEC Course 4