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Henry Ford Hospital 2013 Registration Form

BASIC & ADVANCED CARDIAC LIFE SUPPORT COURSES

You must be certified in BLS and ACLS before you may begin your training. If you have a current

American Heart Association ACLS & BLS card, you do not have to take these courses. Please provide

copy of your certification card to the HFH GME Office. Complete this form to register for BLS and/or

ACLS at Henry Ford Hospital on the dates below.

BLS/ACLS materials will not be mailed outside the USA; they will be provided the day of course.

Please Print

Name (Last, First):

U.S. Mailing Address:

E‐mail Address

Telephone number where you may reached: ( )

Degree:

Residency/Fellowship Program:



I am registering for BLS

on Wednesday June 19, 2013.

The course will take about 2 hours.

Please indicate below the time you would like to start the BLS course.

PLEASE CHECK ONE:

8:00 a.m.

9:00 a.m.

10:00 a.m.

11:00 a.m.

12:00 noon

1:00 p.m.

2:00 p.m.

I am registering for ACLS.

This is a two‐day course: Thursday & Friday, June 20 & 21, 2013

from 7:30 a.m. to 4:30 p.m.

Course Director:

Enrique Enríquez, MD, FACEP

Course Coordinator:

Marilyn Enriquez, RN, BSN, CCRN, CEN

Office: 313‐916‐1987 email: menriqu1@hfhs.org

GME USE ONLY

COST CENTER to be charged:

Diversity Information Page 19

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