Outside Student
ACLS Update Registration Form 

Participants must have a current AHA BLS HealthCare Provider card and a copy of the expiring ACLS card. In order to attend a refresher class, you must have taken ACLS within the last five years. If classes were taken outside Life Support Education, fax a copy of the card to 336-716-5927 with a 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-3rd floor South Building.

If paying by credit card, you may pay on the day of class. Please plan to arrive 10 minutes prior to class starting.


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.