Outside Student TNCC Provider Registration Form

 

Please Note: 
We cannot send out any class materials until we have received payment for the course. 
   
Date to Attend  
Last Name  
First Name  
Middle Initial  
Credentials (MD, RN, etc)  
Address  
City  
State  
Zip Code  
Phone Number  
Employer  
E-mail Address  
Last Four of Your Social Security Number  
Month and Day of Your Birthday (MM/DD)  
Method of Payment  
   
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 by cash, please deliver in person to the Department of Life Support Education on the 3rd floor South Building

If paying by credit card, please call Jill Pettit at 336-716-2888 or stop by Life Support Education.
 
   
Comments/Concerns    
   
We will notify you of your acceptance into the class through the email address you provided in this registration form.  

 

 

Quick Reference

Life Support Education
Tiffany Loggins
For BLS, ACLS, & ITLS Questions

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

Contact Tiffany
tloggins@wakehealth.edu

Jill Pettit
For PALS, NRP, ENPC, TNCC, PITLS, & E-Learning Questions

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

Contact Jill
jpettit@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.