Outside Student ACLS Provider Registration Form

We cannot send out any class materials until we have received payment for the course.  

Participants must have a current AHA BLS HealthCare Provider card (if class taken outside Life Support Education, fax a copy of the card to 336-716-5927 with note stating which class you registered for).


Date to Attend  
Last Name   
First Name   
Middle Initial   
Credentials (MD, RN, etc)   
Zip Code   
Phone Number   
Alternate Phone Number   
E-mail Address   
Last Four of Your Social Security Number
Month and Day of your Birthday (MM/DD)
Fee for Course
Method of Payment:

If payment will be by check, please 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 on the 3rd floor South Building.

If paying by credit card, please call Chelsea Hollifield at 336-716-2888 or stop by Life Support Education.


By choosing “yes,” I understand that I must complete the ACLS precourse assessment, score at least an 80%, print the results, and bring it with me to class. 

To access the precourse assessment, go to www.heart.org/eccstudent and enter this code: compression. 

I understand that if I do not bring the certificate with me, I will not be allowed to take the class.

                 YES, I have read the above statement.

We will notify you of your acceptance into the class through the email address you provided.

Quick Reference

Life Support Education
Mikell White

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

Contact Mikell

Chelsea Hollifield

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

Contact Chelsea


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.