CTC REGISTRATION FORM 1 by S55x5R

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									                                    UNIVERSITY OF SHARJAH
                                         Clinical Training Center
                                                REGISTRATION FORM


All courses delivered at CTC will have CME credit hours certified by the U.A.E MOH and University of Sharjah
                                                                                                                        CTC
                                                                                                                     Clinical Training Center
                                                                                                               Clinical Training at its Best
PERSONAL INFORMATION
Title: Dr. Mr. Mrs.  Ms.

Name: __________________________________________________________________________________
                  (Please write it in Capital and as you would like your name on the certificate)

Phone Number (Office): _______________________                     Mobile: ____________________________________

Email: ___________________________________________________________________________________

Address: _______________________________________ P.O. Box: _________________________________

City: _________________________________ Country: ____________________ Emirate: _______________

Select your method of preferred communication with CTC:

SMS        Phone Call          Email

WORK INFORMATION

Place of Work: ___________________________________________________________________________

Position: ______________________________Area of Specialization: _______________________________

COURSE INFORMATION

Course Name: ____________________________________________________________________________
Date of Course: __________________________________                              College: _________________________________

Please check the other courses you would like to register/inquire about

                                                                    PROVIDE MORE              DATE PREVIOUSLY              FEES
COURSE NAME
                                                                    INFORMATION               TAKEN
EMERGENCY -AMERICAN HEART ASSOCIATION CERTIFICATION
Basic Life Support (BLS)                                                                                                      AED 400
Advanced Cardiovascular Life Support (ACLS)                                                                                   AED 1000
Pediatric Advanced Life Support (PALS)                                                                                        AED 1000
HeartSaver First Aid                                                                                                          AED 300
HeartSaver First Aid/CPR/AED                                                                                                  AED 400
Basic Life Support Instructor Course                                                                                          AED 1200
Advanced Cardiac Life Support Instructor Course                                                                               AED 1500
Pediatric Advanced Life Support Instructor Course                                                                             AED 1500
International Trauma Life Support (ITLS)                                                                                           -

Pediatrics Trauma Life Support (PITLS)                                                                                             -
                                                                     PROVIDE MORE          DATE PREVIOUSLY   FEES
   COURSE NAME
                                                                     INFORMATION           TAKEN
   GENERAL SURGERY
   Basic Surgical Skill Course (BSSC)                                                                         AED 3000
   Minimally Invasive Laparoscopic & Open Techniques in Hernia                                                      -
   Solutions
   Minimally Invasive Operating Techniques in General Surgery                                                       -
   Minimally Invasive Operating Techniques in Gastric Surgery                                                       -
   Minimally Invasive Operating Techniques in Bariatric Surgery                                                     -


   PEDIATRICS
   Minimally Invasive Operating Techniques in Pediatrics
   UROLOGY
   Minimally Invasive Operating Techniques in Urology
   Interventional Endoscopy in Urology
   GASTROENTEROLOGY
   Interventional Endoscopy in upper and lower GI
   GYNECOLOGY
   Minimally Invasive Operating Techniques in Gynecology
   ORTHOPEDICS
   Management of Revision Knee Cases
   High Flexion Solutions for Knee Patients
   The Skilled Surgeon Guide to Handling Severe Knee Cases
   Total Hip Replacement from A to Z
   Hand and Foot Surgical Courses
   Orthopedics Nailing Techniques
   NEUROSURGERY
   Neurosurgical Nurse Forum
   Intracranial Pressure Instructional Course
   NURSES
   Minimally Invasive Operating Techniques for OR Personnel
   The DePuy Trauma Certified Nurse Course
   The DePuy Certified Revision Knee Course


   What are your preferred day/timings of taking the course:                Weekdays        Weekend

                                                                  Morning      Afternoon      Evening

   Where did you hear about CTC ? ____________________________________________________________

   Did you find it easy to register for this course? _________________________________________________

   Comments/Suggestions on courses you would like CTC to offer:




    PAYMENT INFORMATION:
    IN PERSON (Only Cash is accepted)                               WIRE TRANSFER (Only by Bank is accepted)
    Sharjah Surgical and Clinical Institute                         To the order of: University of Sharjah
    Building M-31 Basement, Medical and Health Sciences Campus      Sharjah Islamic Bank
    University of Sharjah                                           Account #002 9200147 001
Contact Details: Tel. : 06 505 7576 / 06 5057582            Swift Code: NBSHAEAS
                          Fax.: 06 5057577
                          E-Mail: ctc@sharjah.ac.ae
                                                    Thank you!
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