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Outside Student ACLS Instructor Registration Form


In addition to this form, please provide a copy of your current BLS card and ACLS card, 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 items listed above, in addition to payment.  

Date to Attend   
Note: 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
Credentials (MD, RN, EMT-P, etc)
Zip Code
Phone Number

Alternate Phone Number

E-mail Address
Method of Payment ($250)

If payment will be by check, please deliver in person to Life Support Education or mail to:

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

Cash payments should be brought to Department of Life Support Education - 3rd Floor, South Building
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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