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
December 19, 2016
 
 
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

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.

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