Online Registration Form

SELECT COURSE & PREFERRED DATES

Course* :
Course Dates * :
Course fee :R

COURSE MANUALS *

Collect books from Emergency Care Education
Books to be couriered(SA only)(R )

TOTAL COURSE FEE

(invoice will be forwarded, once registration form completed)

Personal Information

Title* :
Initials * :
Surname * :
"This is how your name will appear on your certificate."
Full name * :
Identity / Passport number * :
HSPCSA number * :
NA
(Please write in full EG: MP 0123456 or ANT0234567)
" The above will be displayed on your CEU (CPD) certificate."
Hospital / Organisation working at :

Your contact details

Physical Address* :
Postal Code * :
Postal Address * :
Postal Code * :
Phone Number :
Mobile Number *
Fax Number :
E-mail Address * :

Terms and conditions

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