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Employee PALS Instructor Registration Form


In addition to this form, you must provide a copy of your current BLS card and PALS card, as well as a completed Instructor Candidate Application. It can be faxed (336 716-5927) or sent through inter-office mail to Life Support Education. We cannot give out course materials until we receive this information in addition to payment.


Date to Attend   
Please Note: All required forms must be submitted, payment must be received, and materials must be picked up by  October 17, 2017, or you will forfeit your spot in class.
Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, EMT-P, etc)
Zip Code
Phone Number

Alternate Phone Number

Department Name
E-mail Address
Method of Payment ($100)
If you are an employee, and the department is paying, please provide
the department account number to charge for the class and the authorizing person's name.
In addition, the student is responsible for contacting the person who will be paying and asking them to send an email stating intent to pay.
Department Account Number
(full 30-digit billing chart field)
Authorizing Person
If you will be responsible for payment,
how would you like to pay?

If paying by check, please address 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 deliver in person to the Department of Life Support Education or 
call  336-716-2800.
 Please wait until you receive an email of acceptance before calling.
We will notify you of your acceptance into the class through the e-mail address you provided.




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


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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