| APLS: THE PEDIATRIC EMERGENCY MEDICINE COURSE |
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| Application for Course Director Status |
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| * Denotes a Required Field |
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| * First Name: |
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| * Last Name: |
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| * Credentials: |
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| * Street Address: |
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| * City: |
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| * State: |
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| * Country: |
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| * Postal Code: |
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| * Telephone(B): |
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(H): |
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| Fax: |
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* Email: |
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| Academic Appointment: |
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Department: |
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| Institution: |
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City/State: |
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| Clinical Position: |
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| Hospital/Medical Center: |
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City/State: |
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I am board certified in:
Emergency Medicine
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Date:
(mm/dd/yyyy)
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Pediatrics
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Date:
(mm/dd/yyyy)
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Pediatric Emergency Medicine
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Date:
(mm/dd/yyyy)
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Pediatric Surgery
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Date:
(mm/dd/yyyy)
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Family Practice Medicine
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Date:
(mm/dd/yyyy)
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Course Director Qualifications
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Physicians who want to be designated as APLS Course Directors must meet the following criteria:
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1. Have board certification in emergency medicine, pediatrics, pediatric emergency medicine, pediatric surgery, or family practice.
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2. Have a practice in which care provided involves treating pediatric patients.
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3. And one of the following (check appropriate box):
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Have participated in two AAP/ACEP APLS Courses and served as a Faculty member in at least one of those courses.
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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.
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Be a residency/fellowship director. In this case, it is recommended that the applicant observe an APLS Course before serving as Course Director.
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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.)
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I have participated in the following APLS Courses:
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Date:
(mm/dd/yyyy)
Location:
as Student Faculty
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| Please do not click the submit button more than once! |
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