Apply for your Course Online

Please fill in the form below to register for a Course with the ATA International Advanced Training Academy

Applicant Information:

**Please note: all fields marked with a red asterisk (*) are mandatory.**

Full Name (Title, First Name, Initial, Surname) *

Email Address *

Professional Registration No *

ID | Passport Number *

Qualification (Medical, Nursing, EMS) *

Please include date qualified and from which institution qualification was obtained

Contact Information:

Phone *

Fax No

Cell Phone *

Address:

Street Address

City

Country

Postal Code

Postal Address:

Street Address (Postal)

City (Postal)

Country (Postal)

Postal Code (Postal)

Special Dietary Requirements:

Do You Have Special Dietary Requirements?

N.B. You must select Yes or No below to complete this form

YesNo

VegetarianHalaalKosherFood Allergy or Other Dietary Requirements (If selected, Please fill in details below)

Specify Food Allergy or Other Dietary Requirements *

ALS Training Academy Course Information

American Heart Association Programs

Select American Heart Association Course *
N/ABLS for HCPBLS for HCP Instructor*ACLS*PALS*PEARS*
*These courses require that you provide details of BLS for HCP certification

BLS for HCP Certification Date Issued *

BLS for HCP Certification Date of Expiry *

Issued By *

Would you also like to sign up for one of our International Trauma Life Support Programs?

N.B. You must select Yes or No below to complete this form

YesNo

Select ITLS course *
ITLS - basicITLS - Advanced

Please select a course date, as well as an alternative date
Note: if you hover your mouse over the two date fields below, a down arrow will appear on each to bring up a calendar for easy date selection.

Course Date *

Alternative Course Date *

Do you have any challenges we need to know about?
(This information will be kept confidential, but is important to ensure a positive learning experience)
N.B. You must select Yes or No below to complete this form
Do you have any challenges, please select Yes or No *

YesNo

Challenges *
Difficulty With EnglishKnee Or Back ProblemsHearingVisual (Not corrected with glasses/contact lenses)Other (Please Specify)

You Selected *

How did you hear about us?
ColleagueOwn CompanyFire & Rescue International MagazineAttended PreviouslyFacebookReferred by another organisationEmail/Mail ChimpLinkedInWebsiteFlierWord Of MouthMedpagesVia SMSOther
Would you like to receive future correspondence from us?