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HeartCode BLS, ACLS, and PALS Skills Evaluation Registration Form

Section 1 
Last Name  
First Name  
Middle Initial  
Credentials (RN, EMT-P, MD, etc)  
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 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.  


Quick Reference

Life Support Education
Kathy Nelson

Phone 336-716-2005
Fax 336-716-5927

Contact Kathy

Mikell White

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

Contact Mikell


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