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Pediatric International Trauma Life Support Registration Form


Class Date 
First Name  
Middle Initial  
Last Name  
Credentials (RN, EMT-P, MD, etc)  
Zip Code  
Phone Number  
Are you an NCBH Employee?
NCBH Employees: No Fee but must purchase book
Non-NCBH Employees: $100
NOTE: A book is included in the fee for outside students.
If you are an NCBH Employee:    
Employee ID (Required)  
If you are NOT an NCBH Employee:    
Last Four of Social (Required)  

Month and Day of Birthday (Required)

Place of Employment (Required)  

Books and study materials can be picked up from Life Support Education once payment is received.




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


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