NCBH/School of Medicine/WFBH Community Physicians Employee
PALS Instructor Registration Form

PLEASE NOTE:

In addition to this form, you must 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 inter-office mail to Life Support Education. We cannot give out course materials until we receive this information in addition to payment.

 

Date to Attend   
Please Note: All required forms must be submitted, payment must be received, and materials must be picked up by Thursday, March 13, or you will forfeit your spot in class.
Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, EMT-P, etc)
Address
City
State
Zip Code
Phone Number

Alternate Phone Number

Department Name
Department Number
E-mail Address
   
Method of Payment
      
If you are an NCBH employee, and the department is paying, please provide
the department account number to charge for the class and the authorizing person's name.
In addition, the student is responsible for contacting the person who will be paying and asking them to send an email stating intent to pay.
Department Account Number
(full 30-digit billing chart field)
Authorizing Person
   
If you are a School of Medicine or WFBH Community Physicians Employee, and your department
has agreed to cover the cost of this course, please send a signed and completed authorization form
to Life Support Education. This form must be completed by theadministrative person in your department
and allows us to bill your department for the course.
   
If you will be responsible for payment,
how would you like to pay?
      

If paying by check, please address 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 to the Department of Life Support Education or 
call  336-716-2888.
 Please wait until you receive an email of acceptance before calling.
 
Comments/Concerns  
We will notify you of your acceptance into the class through the e-mail 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.