Outside Student
BLS Provider Registration Form 

 

Date to Attend   
Last Name   
First Name   
Middle Initial   
Credentials (MD, RN, etc)   
Address   
City   
State   
Zip Code   
Phone Number   
Alternate Phone Number   
Employer   
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. 

   
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

Chelsea Hollifield

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

Contact Chelsea
chollifi@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.