Outside Student
BLS Provider Registration Form 

 

Date to Attend Time to Attend
January 4, 2017  
January 20, 2017  
January 30, 2017  
February 6, 2017  
February 10, 2017  
February 14, 2017  
March 2, 2017  
March 16, 2017  
March 21, 2017  
March 23, 2017  
   
Last Name   
First Name   
Middle Initial   
Credentials (MD, RN, etc)   
Address   
City   
State   
Zip Code   
Phone Number   
Alternate Phone Number   
Employer   
E-mail Address   
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. 

   
Comments/Concerns  
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
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.

© Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157. All Rights Reserved.