Waiting List Form

CBH Staff Fill out this form if requesting to be placed on the Waiting List for ACLS, PALS, NRP, ENPC, and/or TNCC courses once a class/date is filled. Send one (1) request per course title.

Waiting List Form
* Required Fields
* Last Name:
* First Name:
* Employee ID #:
* Unit/Department:
* Class Title:
* Is this class job-specific for your unit at CBH?:	Yes No
* Indicate RN, LPN, Tech, etc.:	RN LPN MD Tech Other
* Date Requesting (1st choice) (mm/dd/yyyy):
Date Requesting (2nd choice) (mm/dd/yyyy):
* Dept/Unit Extension #:
* Phone 1 (Area/#):
Phone 2 (Area/#):