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The Pediatric Emergency Medicine Resource, Fourth Edition
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Application for Course Director

APLS: THE PEDIATRIC EMERGENCY MEDICINE COURSE
 
Application for Course Director Status

Denotes a Required Field
First Name:
Last Name:
Credentials:
Street Address:
   
City:
State:
Country:
Postal Code:
Telephone(B):  (H):
   Fax: Email:
 Academic Appointment: Department:
 Institution:  City/State:
 Clinical Position:
 Hospital/Medical Center:  City/State:
I am board certified in:
   
Emergency Medicine
Date: (mm/dd/yyyy)
   
Pediatrics
Date: (mm/dd/yyyy)
   
Pediatric Emergency Medicine
Date: (mm/dd/yyyy)
   
Pediatric Surgery
Date: (mm/dd/yyyy)
   
Family Practice Medicine
Date: (mm/dd/yyyy)
 
Course Director Qualifications

Physicians who want to be designated as APLS Course Directors must meet the following criteria:
1. Have board certification in emergency medicine, pediatrics, pediatric emergency medicine, pediatric surgery, or family practice.
2. Have a practice in which care provided involves treating pediatric patients.
3. And one of the following (check appropriate box):
   Have participated in two AAP/ACEP APLS Courses and served as a Faculty member in at least one of those courses.
   Have participated in one AAP/ACEP APLS Course and have a current AAP/American Heart Association (AHA) Pediatric Advanced Life Support course (PALS) instructor card.
   Be a residency/fellowship director. In this case, it is recommended that the applicant observe an APLS Course before serving as Course Director.
   Have had an equivalent teaching experience, or be a course director of an equivalent course. (Please attach a letter detailing this experience if it is not listed specifically on your CV.)
 
I have participated in the following APLS Courses:

Date: (mm/dd/yyyy) Location: as Student Faculty
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