HeartCode BLS, ACLS, and PALS Skills Check-Off Registration Form

 
Section 1 
 
Last Name  
First Name  
Middle Initial  
Credentials (RN, EMT-P, MD, etc)  
Address  
City  
State  
Zip  
Phone Number  
E-Mail Address  
   
Are you an Employee?  
Are you a NCBH, WFUHS, Cornerstone, Wilkes Regional, Community Physicians, or Travel Nurse?  
   
 Employee ID:

 ** There is no charge for online access code as long as you attend your scheduled class.** 
 
Will you need an online access code, or have you already completed the online portion?
(HeartCode BLS Online Part 1, HeartCode ACLS Part 1, or HeartCode PALS Part 1)
 
                                                                          
Section 2 

Select a class or classes desired:
 NOTE: You can sign up for a BLS, ACLS, and PALS check-off in the same day if desired.  

   
HeartCode BLS  
   
HeartCode ACLS (In order to attend ACLS, you must be current in BLS)  
   
HeartCode PALS (In order to attend PALS, you must be current in BLS)  
   
   
Section 3
   
By choosing "yes," I understand that payment will be required BEFORE any online access codes can be issued. Once payment is received, we will email your code to you. If I am an Employee, and receive an online access code I agree to attend class or be charged for the cost of this class.
   
   
To make payment arrangements, please call 336-716-2800 or 336-716-2888.  
Comments/Concerns  

 

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

 

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