Sign Up to Host a PHTLS Provider or Recertification Course - Online Form

Sign Up to Host a PHTLS Provider or Recertification Course - Online Form

Please complete and submit this form.

Hosting Department: 

Your Name: 

Your Phone Number: 

Your E-Mail Address: 

Department's Mailing Address: 

Department's City, State, ZIP: 

Department's Phone Number: 

Department's Fax Number: 

Potential Number of Students: 

 Certification (16 hours of class) 

OR 

 Recertification (8 hours of class)

Requested Dates (Certification: two days,16 hours; Recertification: one day, 8 hours): 

Alternate Dates: 

Thank you for completing this form.

You will receive a phone call or an e-mail from Leif Erickson, Education Coordinator to set up your class.
 

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