Southern Regional AHEC Community Training Center
American Heart Association Emergency Cardiovascular Care Program
1601 Owen Drive, Fayetteville NC 28304 * trainingcenter@sr-ahec.org * Fax: 910.323.0674

Heartsaver ®	Basic Life Support	Advanced Cardiovascular Life Support	Pediatric Advanced Life Support
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Heartsaver ® Course Pathways	Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item.
Heartsaver ® Optional Topics	Click here to enter text.
Must include certificate from online portion for all HeartCode® courses
Lead Instructor: Click here to enter text.	Start Date: Click here to enter a date. Start Time: Click here to enter text.
AHA ID #: Click here to enter text.	End Date: Click here to enter a date. End Time: Click here to enter text.
Instructor Renewal Date: Click here to enter text.	Total Hours of Instruction: Click here to enter text.
TC Name & ID: Southern Regional AHEC CTC NC04286
COURSE INFORMATION
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Student-Instructor Ratio (max 9:1) Choose an item.	City, State: Click here to enter text.
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Must attach instructor card for all instructors not affiliated with the SRAHEC
Instructor Name	Expiration Date	AHA ID # and Training Center Affiliation
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I verify that this course was taught in accordance with American Heart Association guidelines. I confirm that the AHA fee disclaimer was shown or read to the students listed in the attached course roster. I understand that all rosters must be turned in to the SRAHEC within 10 days and all cards must be issued to students within 20 days of course completion. I acknowledge that failure to follow these guidelines will result in remedial training, removal from the TC, or revocation of instructor status at the discretion of the TCC.
Lead Instructor Signature:	Date: Click here to enter a date.

Course Roster Form

Course Date: Click here to enter text.	Course Type: Click here to enter text.	Instructor Name: Click here to enter text.

The American Heart Association strongly promotes knowledge and proficiency in all AHA courses and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the AHA. Any fees charged for such a course, except for a portion of fees needed for AHA course materials, do not represent income to the AHA.

NAME & EMAIL	TELEPHONE #	Skills Assessment	TEST SCORE	REMEDIATION DATE (if applicable)
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