Neonatal Resuscitation Program - Instructor by ebv21247

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									Neonatal Resuscitation Program – Instructor Registration Form
Please type or print or clearly.
For information on NRP Instructor Registration, go to www.cps.ca. Follow the links to NRP and Instructor Resources.

Instructor Information

   Dr.    Mr.     Ms.     Last Name:                                                                                           First Name:

Credential (check only one - your primary role):                 MD              RN             RPN/LPN                RM              RRT              Other: ___________________________________

Instructor level (check one):     Instructor          Instructor trainer           Affiliated hospital/institution: _____________________________________________________________________

Business Address: ______________________________________________________________________________________________________________________________________________

City: ______________________________________                  Province / State: _____________________             Postal /Zip Code: _________________________ Country: _______________________

Tel.: ______________________________________                  E-mail (required for NRP updates and reminders): _______________________________________________

Home Address: __________________________________________________________________________________________________________________________________________________

City: ______________________________________                  Province / State: _____________________             Postal /Zip Code: _________________________ Country: _______________________

Tel.: ______________________________________                  E-mail (required for NRP updates and reminders): _______________________________________________


Preferred MAILING Address:        Business         Home       Preferred BILLING Address:        Business        Home              Preferred LANGUAGE for correspondence:          English      French


Demonstration Course (“Team Teach”)

New instructors must successfully “team teach” an NRP provider course with a registered Instructor Trainer or delegate.
Current instructors: please attach your proof of current status.
  New instructor demonstration (“team teach”) completed
________________________________________________                           ______________________
 Instructor Trainer signature    ID#                                       Date of demonstration



Registration Fee

Instructors are required to pay a registration of $85 every two years. This fee will be used to maintain the database and support the issuing of instructor and provider cards.

   Cheque or money order (payable to the Canadian Paediatric Society)
   VISA      MasterCard         Card #: _____________________________________                Expiration date: _________      Card Holder’s Name: ______________________________________________


  I verify that the information provided on this form is accurate.          Signature: ______________________________________________ Date: ______________________

Confidentiality
Your information will be kept confidential; however the CPS will share NRP data with provincial and national NRP organizations to enable them to monitor the availability of instructor trainers and
instructors.

     Return completed form with payment to: NRP Instructor Registration, Canadian Paediatric Society, 2305 St. Laurent Blvd, Ottawa, ON K1G 4J8 or by fax to 613-526-3332.
                                                            Inquiries: Tel.: 613-526-9397, ext 249 or nrp@cps.ca

								
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