ITLS Pre-Course Checklist

Course Date(s): (i.e. 1/01/10 & 1/02/10)
Course Start Time: (i.e. 0800)
Course Site:
Site Address:
City:
State:
Zip:
Site Phone Number:
Type of Course:
Organization Offering Course:
Organization Address:
Organization City:
Organzition State:
Organization Zip:
Organization Phone Number:
Open or Closed Course:
Course Coordinator Contact Info (to be posted on web site if course is OPEN):
Name:
Phone:
E-mail:
Affiliate Faculty Member:
Approved ITLS Medical Advisor:
Number of Students:
   - denotes required fields