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Employee ACLS Instructor Registration Form


In addition to this form, you must provide a copy of your current BLS card and ACLS cards, as well as a completed Instructor Candidate Application. All four sections of the Instructor Candidate Application must be signed and completed before being sent to us. It can be faxed (336 716-5927) or sent through inter-office mail to Life Support Education. We cannot give out materials until we receive the two items listed above, in addition to payment. 


Date to Attend   
Note: All required forms must be received, class must be paid for, and materials must be picked up by October 10, 2017 or you will forfeit your place in class.
Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, EMT-P, etc)
Zip Code
Phone Number

Alternate Phone Number

Department Name
E-mail Address
Method of Payment ($100)
If you are an NCBH employee, and the department is paying, please provide the department account number to charge for the class and the authorizing person's name. In addition, the student is responsible for having the authorizing person send an email to stating their intent to pay.
Department Account Number
(full 30-digit billing chart field)
Authorizing Person
If you will be responsible for payment,
how would you like to pay?

If payment will be by check please deliver in person or mail to:

Department of Life Support Education
Wake Forest Baptist Medical Center
Medical Center Boulevard
Winston-Salem, NC 27157


If paying in cash, please deliver in person to the Department of Life Support Education - 3rd floor South Building.

If paying by credit card, please deliver in person to the Department of Life Support Education or call 336-716-2800. Please wait until you receive an email of acceptance before calling.

We will notify you of your acceptance into the class through the e-mail address you provided.



Quick Reference

Life Support Education
Kathy Nelson

Phone 336-716-2005
Fax 336-716-5927

Contact Kathy

Mikell White

Phone 336-716-2800
Fax 336-716-5927

Contact Mikell


3rd Floor South Building

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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.

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