Specialty Certification Classes (ACLS) Fall 2024 Registration
Please call   217-524-6749  with your payment information AFTER completing and submitting this form. YOUR REGISTRATION IS NOT COMPLETE UNTIL WE HAVE RECEIVED PAYMENT.
Space in these courses is extremely limited. Registration is required. Walk-ins will not be accepted. 
Registration Fee for ACLS: $60.00 (includes course and certification card)
Registration policy: Registration & Payment must be received a minimum of 8 days prior (11/29/24) to the class date. 
Cancelation and refund policy: Cancelation and refund deadline is 8 days prior (11/29/24) to the class date. 
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Email address *
First Name *
Last Name *
Street Address *
City *
Zip Code *
Phone Number *
Professional License Number *
Scope of Practice *
Attended LLCC in the past? *
Which sessions are you planning to attend? (select all that apply)
*Price includes recertification card. 
NOTE: You must attend the entire course (both days) to get your recertification card. 
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Required
COVID and other communicable diseases statement:
I understand that if I am sick or have symptoms of illness that I need to refrain from attending class. I understand that if I arrive at the course with symptoms of illness that I may be dismissed without refund. 

Please initial below. 

Your initials indicate your understanding and agreement to this COVID and other communicable disease statement.  
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I understand that my registration is not finalized until payment is received.
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How are you paying?
Registration is not complete until you call   217-524-6749  with your credit card information or mail a check to LLCC-Medical District, 130 W. Mason St., Springfield, IL 62702
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