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Employee BLS/PALS Combined Update Registration Form

NOTE:
Participants must present a copy of their expiring PALS card. In order to attend a update class, you must have taken PALS within the last five years. 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.

 

Are you an Employee?
  
If YES, are you an Cornerstone, Wilkes Regional, School of Medicine,NCBH, Community Physicians Employee, or Travel Nurse?
   
Date to Attend   
Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, etc)
Phone Number
Department Name
If Employee, Manager's Name? (First and Last)
E-mail Address
   
Method of Payment:

MD/PA $250.00

NP/PA/EMT-P/etc. $130.00
 
 
 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 336-716-2800 or stop by Life Support Education.  
 

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

To access the pre-course assessment, go to www.heart.org/eccstudent and enter this code: PALS15.

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.

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

 

Quick Reference

Life Support Education
Kathy Nelson
Manager

Phone 336-716-2005
Fax 336-716-5927

Contact Kathy
knelson@wakehealth.edu

Mikell White

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

Contact Mikell
miwhite@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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