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1 Application form for AWLS Course Mexico · [email protected]!!!!...
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www.sosserviciosmedicos.com [email protected] Advanced Wilderness Life Support (AWLS®) Course Application Mexico
Transcript of 1 Application form for AWLS Course Mexico · [email protected]!!!!...
www.sosserviciosmedicos.com [email protected]
Advanced Wilderness Life Support (AWLS®) Course Application -‐ Mexico
www.sosserviciosmedicos.com [email protected]
AWLS Application
Section 1 – Personal Details
Full name
Date of Birth
Nationality
Correspondence Address
Email address (for pre course audio materials)
Alternate email address
Telephone number (incl. country code)
www.sosserviciosmedicos.com [email protected]
Section 2 – Medical Details & Next of Kin
Blood group
Please detail any existing medical conditions or disability and any treatment / medication you are currently taking
Please detail any significant medical history, including that which may affect you should you become ill or injured whilst in Guatemala, such as surgeries, fractures, illness etc
Religion (For repatriation services)
www.sosserviciosmedicos.com [email protected]
Repatriation address / Country
Next of kin (NOK) details / Relationship (In case of any accident or illness)
NOK Full name
NOK Address
NOK Telephone number (landline and mobile)
NOK Email address
www.sosserviciosmedicos.com [email protected]
Section 3 -‐ Application Details
Previous Medical Qualifications
Previous First Aid Experience
Previous Experience Working as a Health Care Professional
www.sosserviciosmedicos.com [email protected]
Reason for attending
Preferred dates (Specify arrival date and start date)
Alternate dates
CME Credits Required
Y / N (Delete as applicable)
www.sosserviciosmedicos.com [email protected]
Payment by bank transfer/PayPal (Delete as applicable)
Details;
Trip cost: - $...................
Additional/Optional CME - $699
Total: $...........................
www.sosserviciosmedicos.com [email protected]
References.
You are required to provide two references, one clinical and one character on the attached Annex A. Please supply the details of your referees below and request they return the completed Annex A as soon as possible.
Not required by Physicians, Nurses, PA’s or EMT-‐Paramedics with current registration
Clinical Referee:
Name:
Address:
Tel No.
Email Address:
Clinical Appointment /Registration No.
Service:
www.sosserviciosmedicos.com [email protected]
Character Reference
Not required by Physicians, Nurses, PA’s or EMT-‐Paramedics with current registration
Additional Information
Name:
Address:
Tel. No.
Email Address:
Personal or Professional Relationship to Applicant:
