Advanced Cardiovascular Life Support Course Roster
Emergency Cardiovascular Care Programs
Course Information
Course Information
ACLS Course
ACLS Update Course
ACLS Traditional Course
ACLS Traditional Update Course
HeartCode ACLS
ACLS EP ACLS
ACLS Instructor Course
ACLS EP Instructor Course
Lead Instructor
Lead Instructor ID
Card Expiration Date
/
Month
/
Day
Year
Date
Training Center
Training Center ID
Training Site Name (if applicable)
Address
City, State ZIP
Course Location
Course Start Date
/
Month
/
Day
Year
Date
Course Start Time
Hour Minutes
AM
PM
AM/PM Option
Course End Date
/
Month
/
Day
Year
Date
Course Start Time
Hour Minutes
AM
PM
AM/PM Option
Total Hours of Instruction
No. of Cards Issued
Student-Manikin Ratio
Please Select
3:1
2:1
1:1
Issue Date of Cards
/
Month
/
Day
Year
Date
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Assisting Instructors
For Instructors aligned with another primary TC, provide copy of instructor card
1. Name and Instructor ID
Card Exp. Date
/
Month
/
Day
Year
Date
2. Name and Instructor ID
Card Exp. Date
/
Month
/
Day
Year
Date
3. Name and Instructor ID
Card Exp. Date
/
Month
/
Day
Year
Date
4. Name and Instructor ID
Card Exp. Date
/
Month
/
Day
Year
Date
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I verify that this information is accurate and truthful and that it may be confirmed. This course was taught in accordance with AHA guidelines.
Signature of Lead Instructor
Date
/
Month
/
Day
Year
Date
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Course Participants
Rows
Name
Email
Telephone
PSA/PW completed
CCF %
Complete/incomplete
remediation/Date completed (if applicable)
1.
2.
3.
4.
5.
6.
STOP!
Only fill out students 7 - 10 if there is a supporting instructor. Go back And fill out a supporting instructor in order to fill out this section!
Course Participants
Rows
Name
Email
Telephone
PSA/PW completed
CCF %
Complete/incomplete
remediation/Date completed (if applicable)
7.
8.
9.
10.
KJ-1958 ACLS 10/25 © 2025 American Heart Association
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