First Name *required		Last Name *required
Address *required		City *required	State	Zip Code
Home Phone *required	Work Phone	Cell Phone:
email *Please include		Profession: *required
ACLS Heartscode: $100.00		Unit / Dept. :
Method of Payment:		Course Date *required June 12, (Sun) 1pm-5pm @ Wayland EMS, 911 S. Main St., Wayland
Check or money order made payable to HEA		To submit this form please answer this simple math question FIRST. 2 + 3=
Online Credit / Debit / Paypal

Cost: $100.00

Confirmation letter with instructions will be sent once registered.

There is a $5 cancellation/transfer policy. If you cancel or transfer to another class, you will be charged $5.

"No Shows" will receive no refund.

For online payment you must use Internet Explorer or Firefox. Payments cannot be received when logged into blackboard.

If you have technical problems with online registration, call Robin at 616-889-0821.

Though our courses follow the American Heart Association Guidelines, other than costs of materials, the American Heart Association does not receive any compensation for these courses.