HEARTCODE PALS
All PALS Courses at the University of Maryland, Baltimore County are taught according to the standards of the
American Heart Association, Maryland Affiliate, Inc.
Continuing Education Credit: This continuing education activity is approved by UMBC, an organization accredited by the Continuing Education Coordinating Board of Emergency Medical Services (CECBEMS).
EMS providers must provide both NREMT # and expiration date (if applicable) and state license and expiration date to receive CECBEMS credit.
Please enroll me in the following: (CHECK ONE) please print legibly
PALS – INITIAL COURSE– ($275.00)
June 13, 2015
(Deadline for registration 6/3/15)
November 8, 2015
(Deadline for registration 10/29/15)
PALS – RENEWAL COURSE* – ($205.00)
TO REGISTER FOR THE RENEWAL COURSE A COPY OF YOUR CURRENT PALS CARD MUST BE SUBMITTED WITH THIS FORM.
June 13, 2015
(Deadline for registration 6/3/15)
November 8, 2015
(Deadline for registration 10/29/15)
You will need to complete your PART I of the course a minimum of 72 hours PRIOR to the class by submitting your Certificate of
Completion of Part I to the PACE Office. Failure to do so will prohibit you from attending the live portion of the class.
Please type or print clearly. A confirmation packet will be sent upon receipt of registration and payment.
You may fax your registration form with credit card information to
~OR~
Mail this completed form and your check made payable to
(410) 455-6713.
"UMBC" to:
UMBC – Department of EHS/PACE
1000 Hilltop Circle, Sherman Hall – A Wing – Room 316
Baltimore, Maryland 21250
Name:
Email:
Address:
City, State, Zip:
Phone:
NREMT-P #:
EMT-P, RN, MD License #:
Alternate Phone:
Exp. Date:
State:
Exp. Date:
Enter Amount
HeartCode PALS Provider Course
$275.00
HeartCode PALS Provider Renewal Course*
$205.00
I wish to purchase an PALS Provider Manual.
$ 43.00
Enclosed is my check in the amount >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Credit Card Convenience processing fee (add to balance above)
$ 5.00
Please charge my VISA MasterCard Discover (please circle one) >>>>>>>>>>>>>>>>>>>>>>>
Card Number:
Address if
different from
above:
V-Code:
(last three digits on back of
card)
Name as it appears on Card:
Expiration Date:
Signature:
“The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course
sponsorship by the American Heart Association. Any fees charged for such a course, except for a portion of fees needed for AHA course materials, do not represent income to the Association.”
Cancellations/Refunds
All registration fees are non-refundable. Registrants may transfer to another course one time (within one year of initial registration) for an additional fee of $45.00.
on will be refunded or transferred to another course date at UMBC's
expense.
I understand that if I have not provided complete state license and NREMT (if applicable) information that I may not receive credit for this course.
Signature: ________________________________________________
I have read and understand the cancellation/refund policy.
Signature: ________________________________________________
For Office Use Only
T-Code: 410 Fund Code: 1113 Prog Fin: 000 Department: 10556 Account: 4873372 Project: CV390043 Actv ID: CNV Resc Type: OPREV
Revised 3/2015
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HEARTCODE PALS
PARTS I & II
Onsite check out @UMBC
Information Sheet
1. Part 1 is completed online using a personalized access code issued by the
American Heart Association via UMBC.
2. PC only; the online portion will not work on Macs.
3. You will need to complete Part I of the course and submit your Certificate of
Completion of Part I to the PACE Office via fax (410-455-6713) a minimum of
72 hours PRIOR to the class. FAILURE TO DO SO WILL PROHIBIT YOU FROM
ATTENDING THE LIVE PORTION OF THE CLASS.
4. Successful completion of this CE activity includes the following:
o Complete the online program.
o Print Certificate of Completion of Part 1.
o Complete the written exam and skills check out at UMBC.
o Complete the course evaluation form.
5. After successful completion of the items above, UMBC will process the course
roster and issue a PALS course card. This card will be mailed to the address
provided on the registration form approximately four business days after the
course conclusion.
6. The on-site check out is for skills testing only. You must come prepared. You
will not have time to practice skills prior to testing.
Revised 3/2015
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