NCBH/School of Medicine Employee
ITLS Registration Form

PLEASE NOTE:
We cannot send out course materials until we receive payment or an account number to charge for the course.  The book is included in the fee for the course.

 

Are you an NCBH or School of Medicine Employee?

*Note to all School of Medicine/Health Sciences 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 area 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, EMT-P, etc)
Address
City
State
Zip Code
Phone Number

Alternate Phone Number

Department Name
Department Number
E-mail Address
   
Comments/Concerns  
We will notify you of your acceptance into the class through the e-mail 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.