NCBH/School of Medicine Employee
ITLS Registration Form

PLEASE NOTE:
We cannot send out course materials until we receive payment or an account number to charge for the course.  The book is included in the fee for the course.

 

Are you an NCBH or School of Medicine Employee?

*Note to all School of Medicine/Health Sciences Employees:
Please send a signed and completed authorization form to Life Support Education
BEFORE the scheduled day of class. This form must be completed by the
administrative person in your area and allows us to bill your department for the course.
This is a requirement to attend class. You can find this form on the Life Support Education
website under FORMS.

 
   
Date to Attend   
 
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 the department is paying, please provide the department account number to charge for the class and the authorizing person's name. An e-mail from the authorizing person confirming their permission to charge the department will also be required.
Department Account Number
Authorizing Person
   
If you will be responsible for payment,
how would you like to pay?
  
   

*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-3rd floor South Building.  
*If paying by credit card, please come by Life Support Education.
   
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.