2-Day Basic Dysrhythmia Course

Registration Form

Sarah Bush Lincoln
EMS Department
104 Professional Plaza
Mattoon, IL 61938
emsgroup@sblhs.org
217-258-2403

* indicates a required field.

Date: *

Name: *

Address: *

City: *

State: *

Zip: *

Phone Number: *

Email:

Course Type:

Initial Provider

Recertification

Agency Affiliation: *

EMS Provider Level: *

Basic - (EMD, EMR, EMT-B)

Advanced - (Paramedic, PHRN, RN, Physician)

Other

Course Date: *

Sept 24, 25 - 8 am to 12 pm

Nov 19, 20 - 8 am to 12 pm

Comments:

We respect and safeguard your privacy. This form is secure.