Basic Cardiac Monitoring Course

Cath Lab and Beyond Potpourri April 28– May 2, 2014

Registration Application

PLEASE COMPLETE & PRINT CLEARLY:

Name:______Address: ______City/State/Zip: ______Nursing License #:______Home Phone:______Work Phone:______Employer:______Department:______

Supervisor’s Signature:______

Clinical Experience (please check) SSNA HOSPITALS Tele __ < 1yr __ 1-5 yrs __ >5yrs Barton Memorial, Catholic Healthcare West - ICU __ < 1yr __ 1-5 yrs __ >5yrs Greater Sacramento Svs Area, Fremont-Rideout, Kaiser Capital Service Area, Kindred Hospital, Cath Lab __ < 1yr __ 1-5 yrs __ >5yrs Marshall Hospital, Methodist Hospital, Northbay, Shriner’s Hospital, Sierra Nevada Memorial, Other: ______Sutter-Auburn, Sutter-Davis, Sutter Medical Center, Sutter-Roseville, UC Davis Medical Course Fee: SSNA Non SSNA Center & Woodland Memorial. Day 1 $120$155 Day 2 $120$155 Day 3 $120$155 Day 4 $120$155 Day 5 (8am – noon) $65 $90 IF SELF PAY – Send completed form with payment to: (Make check payable to Dignity Health) Continuing Education Consortium Dignity Health – Strategic Learning Development HOSPITAL FACILITATOR USE ONLY 1700 Tribute Road, Suite 100 Sacramento, CA 95815 Signature required by facilitator if hospital is responsible for payment. IF HOSPITAL IS RESPONSIBLE FOR PAYMENT FAX completed form to the CEC Coordinator Send completed form to hospital facilitator. Fax: (916) 733-6286

______Facilitator signature required if hospital is paying fee