Pediatric Trauma Life Support Registration Form

 

Class Date 
 
First Name  
Middle Initial  
Last Name  
Credentials (RN, EMT-P, MD, etc)  
Address  
City  
State  
Zip Code  
Phone Number  
E-Mail  
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
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.