Please return this form with your payment to:

Southern Tier ALS
315 West Water Street
Elmira, NY 14901

The fee schedule is printed below. Refunds will not be made without written notification 10 business days or more in advance. All course materials will be mailed to you upon receipt of your registration form and payment. We look forward to serving your training needs!

Name ______________________________      __ RN     __MD/PA/NP      __Paramedic      __ Other

Address ___________________________________   Telephone ______________________________

City/State/Zip __________________________    E-Mail Address ______________________________

Organization Affiliation ________________________  Medical Specialty _________________________

Amount enclosed _________________________      Please check one:    __ Initial Training     __ Renewal

Course and date or which you are registering:

Course: ___________________________________     Date: ______________________________

For more information please call coordinator:
Robert Rajsky, M.S. Ed., AHA Regional Faculty
   (607) 331-3158 or (607) 732-2354 ex 101 or E-mail us at: southerntierals@aol.com

All course materials will be mailed directly to you upon receipt of your registration form and payment.

NOTE: Although these courses are not sponsored by any AHA component, some or all materials utilized by students or faculty may be AHA materials.