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? YesNo Comments