<p> October 23-24, 2015 Carolinas Medical Center Medical Education Building: 6th floor Registration and Pre-payment Required- Deadline: Sept 18, 2015 Email completed registration form to [email protected] Name:______SS#(last 4 digits):______Specialty:______Name of Practice/Hospital:______Home Address:______Telephone: ______Home/Work/Cell (please circle) Email address:______□ATLS Student Cost: $800.00 □ATLS Physician Extender Student Cost: $500.00 □ATLS Refresher Cost: $350.00 - ATLS Exp Date: ______(must be within 6 months after expiration date) Refresher portion is on Oct 24th from approx. 12:00-4:00pm PAYMENT INFO: Check (preferable) Credit Card Departmental Transfer (CHS) Payable to: Name on Card Name of Department Carolinas Healthcare System – Trauma ______Services Card Number Business Unit Number Mail check to: ______Cherry Strickland, Dept of Surgery, Exp Date Department Number Carolinas Medical Center, ______Medical Education Building 6th Floor, 1000 Blythe Blvd., Charlotte, NC 28203 Registration forms will be deleted immediately after processing</p><p>Questions about course: [email protected] or 704-355-6670 Course requirement: min. 16/ max. 24 We reserve the right to cancel course. The American College of Surgeons ATLS Program complies with the American with Disabilities Act (ADA). Any person who needs an accommodation under the ADA should contact George Ross.</p><p>Cancellation/Refund Policy: Registration fee will be refunded if notice of cancellation is received 10 days or more prior to course. Nonrefundable cancellation fee of $50.00 will be retained for any cancellation less than 10 days prior to the course. Refunds will be given only after course materials have been returned. No refunds or rescheduling for unexpected no-shows or cancellations less than three (3) business days prior to course.</p>