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NRP Instructor Registration Form 


NOTE: Before materials can be given out, we must receive 3 items:


1. Copy of current NRP Provider Card
2. Evidence of current training and experience in the hospital care of newborns in a delivery room, newborn, or critical care nursery setting.
3. Payment for the course (call 336-716-2800 if paying by credit card)

Date to Attend  
Last Name  
First Name  
Middle Initial  
Employee ID
(Required if NCBH or School Employee)
Last Four Digits of Social
Required if NOT NCBH or School Employee)
Month and Day of Birthday
Required if NOT NCBH or School Employee)
Credentials (MD, RN, etc)  
Zip Code  
Phone Number  
Department Name (if NCBH)  
Place of Employment  
E-Mail Address  
We will notify you of your acceptance into the class through the email address you provided.




Quick Reference

Life Support Education
Mikell White

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

Contact Mikell

Rebecca Gregory

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

Contact Rebecca


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.

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