Outside Student
BLS Provider Registration Form 


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 the start time. 

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.