Outside Student
ACLS Provider Registration Form 

PLEASE NOTE:
We cannot send out any class materials until we have received payment for the course.  

Participants must have a current AHA BLS HealthCare Provider card (if class taken outside Life Support Education, fax a copy of the card to 336-716-5927 with note stating which class you registered for).

 

Date to Attend
Last Name   
First Name   
Middle Initial   
Credentials (MD, RN, etc)   
Address   
City   
State   
Zip Code   
Phone Number   
Alternate Phone Number   
Employer   
E-mail Address   
Last Four of Your Social Security Number
Month and Day of your Birthday (MM/DD)
Fee for Course
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 in 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 Tiffany Loggins at 336-716-2800 or stop by Life Support Education.

 

By choosing “yes,” I understand that I must complete the ACLS precourse assessment, score at least an 80%, print the results, and bring it with me to class. 

To access the precourse assessment, go to www.heart.org/eccstudent and enter this code: compression. 

I understand that if I do not bring the certificate with me, I will not be allowed to take the class.

                 YES, I have read the above statement.

 
 
Comments/Concerns  
We will notify you of your acceptance into the class through the email address you provided.

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.