IMMEDIATE LIFE SUPPORT (ILS) COURSE 2018- Sri Lanka
Course will be held @ the college of Anaesthesiologists of Sri Lanka –Colombo 8 ( Opposite Lady Ridgeway Hospital – Maradana road entrance)
ILS -Course Fee 2000 Rs
Email address *
1.Select preferred ILS course date *
Target group- Nurses, OPD & Community based doctors,Preinterns
2. Full Name *
As per your ID card/Passport/Birth Certificate
Your answer
3. Surname followed by initials *
e.g; Premaratne E.M.J
Your answer
4. How your name should appear on the certificate *
Please double check the Name.
Your answer
5. First name *
For the name tag
Your answer
6. Mobile number *
Your answer
7. Designation *
If answer is other @Please mention in your comments
8. Specialty / Area of practice *
9. If your answer is "Other" to above question, state the specialty or place of work
Your answer
10. Hospital/ Institution *
e.g , P.G.H Badulla , D.G.H. Gampaha / B.H. Panadura / NHSL / Locum, None
Your answer
11. Date of Birth *
MM
/
DD
/
YYYY
12. NTS/University *
e.g- Colombo University , Kandana NTS or other
Your answer
13. If your answer is "Other for above question, state the University
Your answer
14. Post graduate qualification if any
e.g- Diploma/MSC - Nutrition, DFM,
Your answer
15. SLMC Registration number *
If not registered yet , indicate " No"
Your answer
16. Have you completed any of following life support courses with in last 2 years ? *
17. Meal preference *
18. Any special requests/comments
Different course date, CPR courses done, Special assitance
Your answer
19. I hereby agree that the above information are true and correct according to my knowledge, and will check my email box and respond accordingly *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms