Educational Services | Community Connection

	Community Connection

Community Education Registration Form

Please Type in the name and date of the program you would like to attend:

* Required information
*Program Name:
*Program Date:
For CCMH Employees, please enter your name, dept & ext only. You do not need to enter any additional information.
*First Name:
Middle Initial:
*Last Name:

*Address:
*City:
*State:
*ZIP code:

*Phone:
*E-mail
*Organization


Confirm Identity
*For security purposes, please enter the code you see below:

Cost of programs:

BLS Instr., ACLS, PALS	$150.00
ACLS EP	$100.00
Renewal courses	$75.00
(Renewals book extra + tax) ACLS	$26.50
(Renewals book extra + tax) PALS	$31.80

Make checks payable to: Camden Clark Medical Center

Mail to: Educational Services, PO Box 718, Parkersburg, WV 26102

For more information call: ( 304) 424-2749 or 424-2296

Fax: (304) 424-2688

The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association, and any fees charged for such a course do not represent income to the Association.