Outside Student
ITLS Registration Form

PLEASE NOTE:
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)
Address
City
State
Zip Code
Phone Number

Alternate Phone Number

Employer
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.
   
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.