North Georgia Technical College

North Georgia Technical College Attn: Leslie Foster PO Box 65 Clarkesville, Ga. 30523 American Heart Association Emergency Cardiovascular Care Program Advanced Cardiovascular Life Support and Pediatric Advanced Life Support Course Roster Form

Training Center/Satellite Use Only: Number of Cards Issued______Issue Date of Cards: ______Payment Received /w roster Y or N Check# ______Check Amount $______Cash $______

Course Information □ New Course □ Renewal Course Course Director: Status: □ Instructor/CD □ TC Faculty □ Regional Faculty ACLS ($6.00 / student) Y N □ ACLS Provider □ ACLS EP Provider Lead Instructor: Status: □ Instructor/CD □ TC Faculty □ Regional Faculty PALS ($6.00 / student) Address: □ PALS Provider $6.00  ACLS Provider $6.00  ACLS Instructor Phone: Physician Instructor: Training Center: NORTH GEORGIA TECHNICAL COLLEGE Site Name:

Course Location:

Address:

City, State ZIP: Course Start Date/Time: Course End Date/Time: Total Hrs of Instruction:

# of Cards Issued: Student/Instructor Ratio: TC Use: Issue Date of Cards:

Assisting Instructors/Specialty Faculty (Attach copy of instructor card for instructors aligned with other than primary TC) Name Instr. Card Exp Date TC Module/Station Name Instr. Card Exp Date TC Module/Station 1. 4. 2. 5. 3. 6.

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 DATE: COURSE: COURSE DIR: Course Participants

NAME Remediation/ Complete/ Exam Please PRINT as you wish your name to Address Telephone Date Incomplete Score appear on your card. Completed

1. Y N

2. Y N

3. Y N

4. Y N

5. Y N

6. Y N

7. Y N

8. Y N

9. Y N

10. Y N

ACLS-PALS roster page 2