Course Centre Application - Australian Resuscitation Council

Organisational/Company Name

Course Centre Name*

This is the name the Course Centre will be registered under and listed for courses as.

Contact Address for Course Centre*

Street Address Address Line 2 City State / Territory Post Code Country

All Course centres must be within the Commonwealth of Australia

Contact Phone Number for Course Centre*

Applying for Course Centre Status in:*

Do you have an ARC ALS Instructor planned to Direct your courses

YES
NO

Name of Instructor planning to use as Course Director

First Last

Contact Details For Course Centre Administration

Name of ALS1 Course Coordinator/Administrator*

First Last

Address for ALS1 Administrator (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email of ALS1 Course Coordinator/Administrator*

Enter Email Confirm Email

What are the intended occupations of your intended ALS1 candidate base

Dr's/Medical
Medical Students
Nurses
Paramedics (University/Post Graduate)

Planned number of candidates for each ALS1 course

Please enter a number from 4 to 30.

Number of ALS1 courses to be planned per year

Please enter a number from 0 to 250.

Name: Proposed ARC ALS1 Course Director/Instructor

First Last

Name of the registered ARC Instructor to act as initial Course Director or please indicate if you are discussing with the ARC National Course Coordinator ("in discussion")

Email: Course Director for ALS1

Enter Email Confirm Email

Please leave blank if in discussion with ARC

Name of ALS2 Course Coordinator/Administrator*

First Last

Address for ALS2 Administrator (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email of ALS2 Course Coordinator/Administrator*

Enter Email Confirm Email

What are the intended occupations of your intended ALS2 candidate base

Dr's/Medical
Medical Students
Nurses
Paramedics (University/Post Graduate)

Planned number of candidates for each ALS2 course

Please enter a number from 4 to 30.

Number of ALS2 courses to be planned per year

Please enter a number from 0 to 250.

Name: Proposed ARC ALS2 Course Director/Instructor

First Last

Name of the registered ARC Instructor to act as initial Course Director or please indicate if you are discussing with the ARC National Course Coordinator ("in discussion")

Email: Course Director for ALS2

Enter Email Confirm Email

Please leave blank if in discussion with ARC

Agreement to ARC Regulations

The ARC ALS material is for the express purposes of the courses only and protected under copyright. You may not reproduce or copy either in full or part any of the material for other uses without express written permission. The Australian Resuscitation Council logo may not be used for purposes other than the those needed for the promotion and facilitation of the approved courses. All Courses must abide by the course regulations and failure to comply may result in removal of course centre status. Course centres are aware that an ARC delegate may undertake a review of the course centre at any time without notice.

Name: Organisational Manager/Executive with fiscal responsibility*

First Last

Please give name of person agreeing to financial commitments of the courses. This may need to be a manager or executive member with fiscal responsibilities for the course centre. All Course certificated places are invoiced on dispatch of manuals for the course. Terms are 30 days from dispatch. Failure to comply with financial aspects of the administration of couses may result in loss of course centre status.

Email: Organisational Manager/Executive with fiscal responsibility*

Enter Email Confirm Email

Contact Phone Number of Manager/Executive

Name of person completing form*

First Last

Position/role title of person completing form*

Email: person completing form*

Enter Email Confirm Email

Contact Phone Number of person completing form

Date

Course Centre Application Form

Contact Details For Course Centre Administration

Agreement to ARC Regulations