Employee BLS Instructor Registration Form

PLEASE NOTE:

In addition to this form, you must provide a copy of your current BLS Provider 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 two items listed above, in addition to payment. 

Date to Attend   March 28, 2017

Note: All required forms must be received, class must be paid for, and materials must be picked up by March 23, 2017 or you will forfeit your place in class.

Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, EMT-P, etc)
Address
City
State
Zip Code
Phone Number

Alternate Phone Number

Department Name
E-mail Address
   
 Method of Payment ($100)
                     
   
 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.
   
   
Comments/Concerns  
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
miwhite@wakehealth.edu

Rebecca Gregory

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

Contact Rebecca
rbgregor@wakehealth.edu

 

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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