***Enrollment Deadline 6 Weeks Prior to Course Date***

A BASIC DYSRYTHMIAS COURSE IS A MANDATORY PRE-REQUISITE FOR ALL FIRST TIME RN, LPN, CNA, HM, 68W, & EMT STAFF

WalterReedNationalMilitaryMedicalCenter PEDIATRICADVANCEDLIFESUPPORTCOURSESCHEDULE

HEALTH EDUCATION AND TRAINING 2014 - 2015

ENROLLMENT INTO ANY RESUSCITATIVE MEDICINE COURSE IS DONE VIA PAPER APPLICATION THAT CAN BE OBTAINED THROUGH HOSPITAL EDUCATION AND TRAINING WEBPAGE OR BY CALLING 301-400-0878

Renewal Course Date Provider Course Date Instructor Course Date

30 July 2014 28-29 July 2014 N/A

21 August 2014 19-20 August 2014 18-20 August 2014

24 September 2014 22-23 September 2014 N/A

16 October 2014 21-22 October 2014 20-22 October 2014

17 November 2014 3-4 November 2014 N/A

2 December 2014 8-9 December 2014 N/A

28 January 2015 26-27 January 2015 N/A

19 February 2015 24-25 February 2015 23-25 February 2015

25 March 2015 23-24 March 2015 N/A

29 April 2015 27-28 April 2015 N/A

29 May 2015 26-27 May 2015 TBD

17 June 2015 15-16 June 2015 (Interns Only) N/A

29 July 2015 27-28 July 2015 N/A

27 August 2015 25-26 August 2015 24-26 August 2015

30 September 2015 28-29 September 2015 N/A

WALTER REED NATIONAL MILITARY MEDICAL CENTER HEALTH EDUCATION AND TRAINING

RESUSCITATIVE MEDICINE EDUCATION & TRAINING APPLICATION

Please fill out application completely and return with copies of current BLS/ACLS/PALS cards via email to the Resuscitative Medicine Program Director, Jennifer Fellows, jennifer.b.fellows.civ@health.mil. You will be notified of the receipt of your application within one week.

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR ENROLLMENT CONTRACTORS ARE INELIGIBLE FOR TRAINING

COURSE INFORMATION DATE OF APPLICATION: COURSE REQUESTED: (SELECT ONE) ACLS PALS ATLS BLS INSTRUCTOR COURSE COURSE TYPE: (SELECT ONE) 1ST-TIME PROVIDER RENEWAL ACLS / PALS INSTRUCTOR DESIRED COURSE DATE: PERSONAL INFORMATION NAME: *GRADE/RANK/CORPS: DESIGNATOR/NEC: BRANCH: ARMY NAVY AIR FORCE PHS MARINE CORPS RESERVIST DOD EMPLOYEE POSITION: MD DO PA NP RN LPN 68W EMT HM OTHER: (SPECIFY) CONTACT INFORMATION CLINICAL / WORK AREA: SUPERVISOR NAME AND EMAIL (PRINT CLEARLY): FACILITY: (WRNMMC /PENTAGON/ WHMO/FBCH): WORK & PERSONAL E-MAIL: DUTY PHONE (INCLUDE AREA CODE): HOME / CELL PHONE (INCLUDE AREA CODE): EXPIRATION DATES: BLS EXPIRATION DATE: ATTACH A COPY OF CURRENT BLS CARD (FRONT AND BACK) DATE OF BASIC DYSRYTHMIAS COURSE: (MANDATORY FOR ALL RN, LPN, CNA, 68W, CORPSMAN & EMT STAFF) IF APPLYING FOR RENEWAL COURSE, EXPIRATION DATE OF CURRENT CERTIFICATION:

ACLS EXPIRATION DATE: PALS EXPIRATION DATE: ***IF YOUR CURRENT CARD IS EXPIRED YOU DO NOT QUALIFY FOR A RENEWAL CLASS***

ATTACH A COPY OF CURRENT ACLS/ PALS CARD (FRONT AND BACK) STUDENT STATEMENT OF UNDERSTANDING:

1. Request for application to the above mentioned course DOES NOT guarantee selection to the program. 2. Enrollment deadline ends 6 weeks prior to the start date of the course. Student selection will be made at that time and seated in order of

Priority. Any applications received after the deadline will be seated on a first come first serve basis or placed on a waiting list in the order of applications received.

3. Military Reservists must be on active training orders in order to attend class and MUST be in uniform. 4. Uniform of the day is required for military staff. Appropriate dress is required for civilian staff. No Scrubs!!!! 5. You will receive a Welcome Letter stating the dates you may pick up course materials. Failure to pick up the course materials by the last

designated day will result in forfeiture of your seat in the requested class. 6. If you are unable to attend the course, you or your supervisor must notify SFD at least 24-hours prior to the class start date. 7. FAILURE TO NOTIFY OR ATTEND CLASS WILL RESULT IN A “NO SHOW” STATUS AND ACCEPTANCE INTO THE NEXT CLASS

WILL BE CONTINGENT ON A LETTER FROM YOUR SECTION CHIEF. Signature: ____________________ Supervisor’s Signature: ___________________ Date__________ 1st Priority: Physicians, Physician Assistants and Nurse Practitioners working in Critical Care, Code Blue Team, ER, PACU, OR, areas utilizing sedation, or Peds Clinic, PICU,

NICU, MICC (PALS) assigned to WRNMMC and the affiliated Branch Health Clinics. 2nd Priority: Registered Nurses working in Critical Care, Code Blue Team, ER, PACU, OR, areas utilizing sedation, or Peds Clinic, PICU, NICU, MICC (PALS) assigned to

WRNMMC and the affiliated Branch Health Clinics. 3rd Priority: Licensed Practical Nurses, 68W, HM and EMT’s working in Critical Care, ER, PACU, OR, areas utilizing sedation, or Peds Clinic, PICU, NICU, MICC (PALS)

assigned to WRNMMC and the affiliated Branch Health Clinics. 4th Priority: Physicians from all other clinical areas at WRNMMC, the affiliated Branch Health Clinics and those not assigned to WRNMMC. 5th Priority: Registered Nurses and Licensed Practical Nurses from all other clinical areas at WRNMMC, the affiliated Branch Health Clinics and those not assigned to

WRNMMC. 6th Priority: All other medical personnel from clinical areas at WRNMMC, the affiliated Branch Health Clinics and those not assigned to WRNMMC.