Outside Student
ITLS Registration Form

We cannot send out course materials until we receive payment for the course.


Date to Attend      
Last Name
First Name
Middle Initial
Credentials (MD, RN, EMT-P, etc)
Zip Code
Phone Number

Alternate Phone Number

E-mail Address
Last Four of Your Social Security Number
Month and Day of Your Birthday (MM/DD)
Method of Payment ($85)

*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, please come by Life Support Education or call Mikell White at 336-716-2800.
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

Chelsea Hollifield

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

Contact Chelsea


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.