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ACLS Instructor Registration Form

This course is designed for the ACLS Provider that has demonstrated excellence in ACLS concepts and wishes to achieve instructor status.

 Prerequisites:

 

  1.  Completed Instructor Candidate Application. indicating your instructor commitment, your acceptance by an AHA Training Center, and your verification of Instructor Potential. This form can be found under the "forms" tab on our website.You will need to contact your most recent ACLS instructor to verify your instructor potential, and you must contact the training center that you would like to join and have them sign TC Alignment section. Please do not send this form until ALL four sections have been filled out. 
  2. Current AHA BLS  Provider and ACLS Provider cards. 
  3. Participants must obtain a copy of a current ACLS Provider Manual (available in LSE).

 

Fees

Outside Students: $250
*Refunds will not be given if you are unable to attend this class. Please do not pay for a class unless you are prepared to attend the class date that you have scheduled. If unable to attend your scheduled date, we will gladly move you to a different day that will work with your schedule.
 Employees: $100

ACLS Instructor Course Times: 8am - 5pm

IMPORTANT: Registration must be received, all forms must be sent, payment must be received, and materials must be picked up by March 5, 2018, or you will not be allowed to attend class.

 

Date to Attend   
                          
Are you an Employee?  
              
If YES, are you a NCBH, WFUHS, Cornerstone, Community Physicians, Wilkes Regional, or Travel Nurse?
IF NO, place of Employment?
   
Last Name
First Name
Middle Initial
Employee ID
If Employee, Manager's Name / Department
Credentials (MD, RN, EMT-P, etc)
Address
City and State
Zip Code
Phone Number
E-mail Address
Method of Payment

Employee $100.00

Non-Employee $250.00 
           
If you are an 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 miwhite@wakehealth.edu stating their intent to pay.
Department Account Number
(full 30-digit billing chart field)
Authorizing Person
 

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.

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

 

 

Quick Reference

Life Support Education
Kathy Nelson
Manager

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

Contact Kathy
knelson@wakehealth.edu

Mikell White

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

Contact Mikell
miwhite@wakehealth.edu

 

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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