Training Center - Online Application

Healthcare, emergency response, or educational institutions interested in training students and/or personnel utilizing the Advanced Stroke Life Support® curriculum and its instructional tools may apply to become an ASLS® Training Center with the Gordon Center by completing the electronic form below. Those that have already been conducting ASLS® courses must also submit an application as part of the process of registering as an ASLS® TC. Regarding questions in the form:
• If your intended audience encompasses both prehospital providers and in-hospital personnel, select from the drop-down menu Provider P/H Combo.
• If you already own the curriculum package/instructor tools to teach ASLS®, click the box beside Have Materials.
• If there are instructors available to you already trained to teach ASLS® courses, click the box beside Previously Trained Instructors and enter the names in the spaces provided. If you have more than three, enter the additional names in the Comments box provided.

Before submitting the form, you must click two boxes stipulating your ACCEPTANCE of the terms and conditions and agreement to abide by the posted guidelines. Hyperlinks to both pdf files are found at the bottom of the form, above the submit button, so please read the documents before entering your data in the form. No form can be submitted without the acceptance boxes checked off.


 

Organization Information:

     
Organization Name:        
Department:    
Discipline:    
select
 
Parent Company or System:    
Organization Type:  
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Organization Sub-Type  
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Address & Contact:

Address 1:        
Address 2:      
City:        
State:  
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Zip:      
County (if in FL):  
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Phone Number:      
Phone Extension:    
Fax Number:    
Website:    
Shipping Address 1:        
Shipping Address 2:      
Shipping City:        
Shipping State:  
select
 
 
Shipping Zip:      

Individual Applying:

First Name:        
Last Name:      
Title:       
Address 1:        
Address 2:      
City:        
State:  
select
 
 
Zip:      
FL County:  
select
 
Phone Number:      
Phone Extension:    
Fax Number:    
Cellular:    
Pager:    
Pager Code:    
Email Address:        

Training Center:

Intended Trainees:    
select
 
 
     
      
     

Instructor Information:

     
     
Instructor #1 First Name:    
Instructor #1 Last Name:    
     
Instructor #2 First Name:    
Instructor #2 Last Name:    
     
Instructor #3 First Name:    
Instructor #3 Last Name:    
     

Comments:

     

Submit:

 
By clicking on the “Submit” button, you affirm that:

 

 
 
     
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