NCBH/School of Medicine/WFBH Community Physicians 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 Friday, October 14, 2016 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
Department Number
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 are a School of Medicine or WFBH Community Physicians Employee, and your department has agreed to cover the cost of this course, please send a signed and completed authorization form to Life Support Education. This form must be completed by the administrative person in your department and allows us to bill your department for the course.
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
Mikell White

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

Contact Mikell

Rebecca Gregory

Phone 336-716-2888
Fax 336-716-5927

Contact Rebecca


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.