Outside Student
PALS Instructor Registration Form


In addition to this form, please 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 the mail to Life Support Education. We cannot give out course materials until we receive this information.


Date to Attend   
Please Note: All required forms must be submitted, payment must be received, and materials must be picked up by Friday, October 14, 2016, or you will forfeit your spot in class.
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 ($250)

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 deliver in person 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 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

Find a Doctor Ways to Give
USNWR 2015-2016Magnet Hospital RecognitionConsumer Choice2015 Best DoctorsJoint Commission Report

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.