EmailMe Form - Course Centre Application Form

EmailMeForm

Please ensure the form below is completed accurately.

For full descriptions of courses please see the ‘Courses’ page
Organisational/Company Name
Course Centre Name *
Contact Address for Course Centre *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Contact Phone Number for Course Centre *
Applying for Course Centre Status in:
Do you have an ARC ALS Instructor planned to Direct your courses
Contact Details For Course Centre Administration

Name of Course Coordinator/Administrator *
First Middle Last
Address for Administrator (if different from above)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email of Course Coordinator/Administrator
What are the intended occupations of your intended candidate base *
Nurse
Dr
Paramedic
Medical Student
Dentist
Anaesthetic/Cardiac Technician
Allied Healthcare Professional
Other
Planned number of candidates for each course
Number of courses to be planned per year
Name: Proposed ARC Course Director/Instructor *
First Middle Last
Email address *
Name of Organisational Executive / Head of Education supporting this training *
First Last
Email of above *
Agreement to ARC Regulations
The ARC ALS material is for the express purposes of the courses only and protected under copyright. You may not reproduce or copy either in full or part any of the material for other uses without express written permission. The Australian Resuscitation Council logo may not be used for purposes other than the those needed for the promotion and facilitation of the approved courses. All Courses must abide by the course regulations and failure to comply may result in removal of course centre status. Course centres are aware that an ARC delegate may undertake a review of the course centre at any time without notice.
Name: Organisational Manager/Executive with fiscal responsibility* *
First Middle Last
Please give name of person agreeing to financial commitments of the courses. This may need to be a manager or executive member with fiscal responsibilities for the course centre. All Course certificated places are invoiced on dispatch of manuals for the course. Terms are 30 days from dispatch. Failure to comply with financial aspects of the administration of couses may result in loss of course centre status.
Email: Organisational Manager/Executive with fiscal responsibility* *

Confirm
Contact Phone Number of Manager/Executive
Name of person completing form *
First Middle Last
Position/role title of person completing form *
Email: person completing form *

Confirm
Contact Phone Number of person completing form
Date
DD / MM / YYYY

Agreement to ARC Regulations