UAB/BREMSS ATLS Course Registration

Course Type *

Course ID *

Course Date *

Course Times

First name *

Middle Name/Initial

Last name *

Card Display Name

This is how you want your name to appear on your certification card upon successful completion

Email *

Confirm the previous field *

Secondary Email (if applicable)

Mobile Phone *

Address *

City *

State *

Zip Code *

Participant Type *

Other *

Credentials *

Other *

Haver you taken ATLS in the past? *

Current or most recent ATLS Expiration Date *

ATLS ID Number

Leave blank if you are taking ATLS for the first time or if you do not know the number. This information is important when officially enrolling you in the ACS system.

What is your specialty? *

(i.e., Emergency Medicine, General Surgery, Family Medicine, etc)

Are you a Surgeon? *

Are you active US Military?

Military Branch *

Company name *

Job title *

Phone

Street

Post box

City

State

Zip code

Country

Invoice Employer for course tuition

Residency Program

Other *

Residency Coordinator Information

First name

Last name

Email

Your order reference or P.O. *

Invoice to the attention of *

Same as company information

Invoice - Company name *

Invoice - Street *

Invoice - Post box

Invoice - City *

Invoice - State *

Invoice - Zip code *

Do you have food allergies or dietary restrictions? *

Food Allergy/Dietary Restriction Explanation

Acknowledgement Statement *

By checking this box, I confirm that I have read, understood, and agree to comply with policies related to the course in which I am registering. I acknowledge that it is my responsibility to adhere to the guidelines and requirements outlined in the policy related to the course.

Electronic Signature *

I hereby certify that all information provided in this submission is accurate and complete to the best of my knowledge. I also confirm that I have read, understood, and agree to comply with all course requirements as outlined.

Contact information

Professional Information

Company information

Residency Information

Invoice information

Food Allergy/Dietary Restriction Information

Course Policies and Completion Requirements

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