BLS Refresher Registration Form - Outside Student  

NOTE: Find the date you would like to attend on the left, and pick a time to attend that class on the right. Please choose only ONE date and time to attend. 

 

Date to Attend Time to Attend
May 1, 2015       
May 13, 2015  
May 29, 2015
June 3, 2015  
June 17, 2015
June 30, 2015
July 6, 2015
July 17, 2015
July 31, 2015
August 4, 2015
August 14, 2015
August 31, 2015
September 1, 2015  
September 11, 2015  
September 30, 2015  
 
 
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 the day of class unless you are attending a class after 5pm. If attending an after-hours class, please call 336-716-2800 or 336-716-2888 to pay.
   
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.