ENPC Provider Registration Form  


NCBH, School of Medicine, and WFBH Community Physicians Employee

Are you an NCBH, School of Medicine, or
WFBH Community Physicians Employee
Note to ALL School of Medicine/Health Sciences and WFBH Community Physicians Employees:
Please send a signed and completed authorization form to Life Support Education BEFORE the scheduled day of class. This form must be completed by the administrative person in your are and allows us to bill your department for the course. This is a requirement to attend class. You can find this form on the Life Support Education website under "FORMS."
Date to Attend  
Last Name  
First Name  
Middle Initial  
Employee ID  
Credentials (MD, RN, etc)  
Phone Number  
Department Name  
Department Number  
E-mail Address  
We will notify you of your acceptance into the class through the email address you provided in this registration form.  



Quick Reference

Life Support Education
Mikell White

Phone 336-716-2800
Fax 336-716-5927

Contact Mikell

Rebecca Gregory

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

Contact Rebecca


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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.