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 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: acls15. 

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

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.

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