Registering for Advanced Cardiac Life Support (ACLS) - Experienced Provider, UW Health, University of Wisconsin Hospital, Madison

Thank you for your interest in the classes offered by the UW Health Emergency Education Center (EEC), formerly the Emergency Medical Services Program (EMS). In order to register you for a class, we will need the following information. We will then contact you to confirm your registration and discuss payment options (generally, you may submit your course fee when you attend your class).

Please complete all the form fields below. Thank you.

First Name

Last Name

Phone Number (include area code)

Home Cell

Mailing Address

Include street address or P.O. Box, city, state and Zip code:

Course Title

I would like to register for the following class:

ACLS-EP - Advanced Cardiac Life Support (Experienced Provider) (View Course Details)

Course Session - Date and Time

Please indicate the date/time for which you would like to register for the class you selected (select the View Course Details links above to view the available class sessions).

Expiration Date

Please indicate your American Heart Association expiration date below:

Professional Information

Are you an employee of UW Hospital and Clinics?

Yes No

If you are a UW Hospital and Clinics employee, please list your job title, department and employee ID number:

REQUIRED for UW Hospital and Clinics Employees:

Department/Work Unit (not required for outside staff)

Job Title (not required for outside staff)

E-mail Address (not required for outside staff)

Subject (not required for outside staff)

UW Employee ID Number (not required for outside staff)

If you are NOT a UW Hospital employee, please indicate where you work:

How did you hear about our classes?

On the Web
Class brochure

A professional organization

Word of mouth
My employer

An advertisement (newspaper/radio/TV)

Flier in an Emergency Department

Other (please specify below)