C A R E P r o g r a mP a y m e n t F o r m

Participant Information

Full Name:

Credential:

Hospital and Department:

E-mail Address (required):

Registration InformationPlease select the appropriate course and indicate course date:

Course (book materials not included) Fee: Course Date:

o PALS Provider class $250

o PALS Renewal class* $150

o PEARS class $150

o ACLS Renewal class* $152

o PALS HeartCode (online) class $210

o ACLS HeartCode (online) class $210

o BLS HeartCode (online) class $46

* Please submit copy of current card

o BLS HeartCode Add-on (available for all courses) $46

Payment Information

o Card payment: Visa/MasterCard accepted. Details provided during registration confirmation. o Check payment: Please make checks payable to OHSU CARE.

Please send payment to:

OHSU CARECollaborative Life Sciences BuildingMailcode: CL4C2730 SW Moody Ave.Portland, OR 97201

Center for the Advancement of Resuscitation Educationcare@ohsu.edu | 503.346.4425