AHA EMS Intent to Train Form - Birmingham Regional EMS System

Fill form with idloom.passport

Login with idloom.passport

No account yet? Please register to this event and your account will be created automatically.

Or

Today's Date *

Course Information

Course to be taught *

Course Format *

Course Options: [ACLS - ILT Full Course; ILT Traditional Full Course; ILT Traditional Update/Renewal Course; ILT Full Update/Renewal Course ;HeartCode] [BLS - ILT Full Course; ILT Update/Renewal Course; HeartCode] [PALS - ILT Full Course; ILT Traditional Full Course; ILT Traditional Update/Renewal Course; ILT Full Update/Renewal Course ;HeartCode] [PEARS - ILT Full Course]

Course Start Date

Course Start Time *

Course End Date

Course End Time *

Number of Prospective Students *

Are the students part of an established EMS Program? *

EMS Program Contact First name

EMS Program Contact Last name

EMS Program Contact Email

Course Coordinator/Lead Instructor

First name *

Last name *

Email *

Job title *

Street *

City *

State *

Zip Code *

Mobile Phone *

Office Phone

Sponsoring Agency

Agency Name *

EMS Agency Training Director *

EMS Region *

County *

Course Specifics

Will you have sufficient faculty to observe AHA recommended instructor/student ratios? (6 students, 2 manikins, 1 instructor – 6:2:1) *

What is your plan for assuring appropriate equipment availability and maintaining AHA recommended student/manikin ratios? *

Additional Instructors

Add 2nd Instructor

Attesting Statements To the best of my ability and knowledge, all the statements contained in this application are true and accurately represent the proposed continuing education activity.

Course Coordinator Signature *

Type your name in the box .

Student Roster You must submit a roster of prospective students prior to an approval being granted. The roster may be a template already used in your agency.

Preliminary Course Roster *

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Registration fees

Registration to this event

body, html { margin: 0; padding: 0; font-family: 'Open Sans', sans-serif; overflow: hidden; } * { box-sizing: border-box; } .container-404 { background: url('https://online.bremss.org/images/manager/errors/ConferenceRoom_optimized.jpg'); background-repeat: no-repeat; background-size: cover; height: 120%; width: 100%; position: relative; background-position: 0% 50%; z-index: 9999999; position: absolute; top: 0; left: 0; right: 0; bottom: 0; } .content-404 { background: rgba(255, 255, 255, 0.97); text-align: center; width: 600px; position: absolute; top: 50%; left: 50%; margin-left: -300px; margin-top: -230px; border-radius: 2px; box-shadow: 0 3px 6px rgba(0, 0, 0, 0.16), 0 3px 6px rgba(0, 0, 0, 0.23); color: #454545; padding: 15px 30px; animation: fadein .8s ease-out 1; animation-fill-mode: forwards; animation-delay: 0.1s; } .logo-idloom-404 { position: relative; top: 0px; opacity: 0; animation: position .5s ease-out 1; animation-fill-mode: forwards; animation-delay: 0.2s; } .logo-idloom-404 img { width: 180px; max-width: 100%; } .content-404 h2 { font-size: 18px; margin: 40px 0; position: relative; top: 0px; opacity: 0; animation: position .5s ease-out 1; animation-fill-mode: forwards; animation-delay: 0.4s; } .content-404 h3 { position: relative; top: 0px; opacity: 0; animation: position .5s ease-out 1; animation-fill-mode: forwards; animation-delay: 0.6s; font-size: 16px; margin-top: 40px; } .content-404 a { text-decoration: none; color: white; } .content-404 h3>a, .content-404 p>a { color: #1ebae2; } .content-404 h3>a:hover, .content-404 p>a:hover { color: #1094b5; } .content-404 .btn-back-404 { max-width: 180px; width: 80%; padding: 10px 5px; border-radius: 2px; box-shadow: 4px 4px 8px rgba(0, 0, 0, 0.16), 3px 4px 18px rgba(0, 0, 0, 0.23); margin: auto; display: block; margin-bottom: 40px; transition: all .2s ease-out; border: 1px solid #1ebae2; position: relative; z-index: 2; overflow: hidden; top: 0px; opacity: 0; animation: position .5s ease-out 1; animation-fill-mode: forwards; animation-delay: 0.8s } .content-404 .btn-back-404:hover { box-shadow: 0 0px 0px rgba(0, 0, 0, 0.16), 0 0px 0px rgba(0, 0, 0, 0.23); z-index: 10; color: #38B4C6; } .content-404 .btn-back-404 span { font-size: 14px; font-weight: 600; color: #bef1ff; transition: all .2s ease-out; } .content-404 .btn-back-404:hover span { color: #0b99bd; } .content-404 p { color: #909090; position: relative; top: 0px; opacity: 0; animation: position .5s ease-out 1; animation-fill-mode: forwards; animation-delay: 1s } .btn-back-404::before { content: ''; position: absolute; z-index: -1; -webkit-transition: all .4s cubic-bezier(0.29, 0.76, 1, 1); transition: all .4s cubic-bezier(0.29, 0.76, 1, 1); width: 110%; height: 600%; top: 50%; left: 50%; background: #1ebae2; opacity: 1; -webkit-transform: translateX(-50%) translateY(-50%) rotate(-45deg); transform: translateX(-50%) translateY(-50%) rotate(-45deg); } .btn-back-404:hover::before { height: 0%; opacity: .1; } @keyframes fadein { from { opacity: 0; top: 53%; } to { opacity: 1; top: 50%; } } @keyframes position { from { opacity: 0; top: 10px; } to { opacity: 1; top: 0; } } @media screen and (max-width: 1680px) { .container-404 { background: url('https://online.bremss.org/images/manager/errors/ConferenceRoom1680_optimized.jpg'); background-repeat: no-repeat; background-size: cover; background-position: 0% 50%; } } @media screen and (max-width: 640px) { .content-404 { width: 380px; margin-left: -190px; margin-top: -180px; padding: 15px 10px } .content-404 h2 { margin: 20px 0; font-size: 20px; } .content-404 h3 { font-size: 16px; } .logo-idloom-404 img { width: 140px; } .content-404 .btn-back-404 { margin-bottom: 20px; } } @media screen and (max-width: 375px) { .content-404 { width: 300px; margin-left: -150px; } .container-404 { background-position: 20% 50%; } }

For full functionality of this site it is necessary to enable JavaScript.

Here are the instructions how to enable JavaScript in your web browser.

If the problem persists, please contact your system administrator.